Redo Aortic Surgery: Thoughts on New Technologies

Om P Yadava of the National Heart Institute in New Delhi, India, and Roberto Di Bartolomeo of the University of Bologna in Italy discuss the redo aortic surgeries and recent advances like the frozen elephant trunk and endovascular repair.

Dr Yadava begins by asking why redo aortic surgeries are needed and what their incidence is. Dr Di Bartolomeo responds that the incidence of redo aortic surgeries is increasing for multiple reasons: the increasing age of the population, more use of bioprosthetic valves (currently around 80% in the USA), and increasing incidence of infection of the valves and endocarditis. Furthermore, a number of patients with previous type A or type B acute aortic dissection surgeries are now presenting with dilated aortas and have contributed to the increasing incidence of redo surgeries. Dr Di Bartolomeo notes that in almost all patients after surgery for type A dissection, the false lumen remains patent and tends to increase and dilate, more so in patients with hypertension and where the primary entry tear had not been handled in the first instance.

Dr Di Bartolomeo goes on to discuss the indications of extended operations in type A aortic dissection, especially the frozen elephant trunk (FET). He feels that for patients who are young, who have primary lesions in the aortic arch or who have acute type B aortic dissection with retrograde extension into the arch or the ascending aorta, and those with impending rupture of the ascending aorta, an extended operation is very much needed to improve long-term results. The indications are heavily dictated and influenced by the experience of the surgeon. Dr Di Bartolomeo opines that the aortic valve should be preserved if the surgeon has enough experience with aortic valve repairs. He goes on to discuss the need for post-FET interventions and the various options that are available for them like thoracic endovascular aortic repair or open surgical options. He elaborates on the use of Cosseli prosthesis with the side branches for repair or replacement of the abdominal aorta and its advantages in terms of spinal cord protection and very few renal issues.

Suggested Reading

1. Di Bartolomeo R, Leone A, Di Marco L, Pacini D. When and how to replace the aortic arch for type A dissection. Ann Cardiothorac Surg. 2016;5(4):383-388.