A history of open thoracoabdominal aortic aneurysm repair: perspective from Houston.

As late as the early 1950s, ligation, cellophane wrapping, endoluminal wiring, endoaneurysmorrhaphy, and other techniques were well-accepted treatments for aneurysm. Techniques aimed at repair of syphilitic and saccular aneurysms of the proximal aorta were largely unsuitable for the larger, fusiform atherosclerotic aneurysms of the thoracoabdominal aorta. The earliest replacements of the thoracoabdominal aorta relied on the use of donor homografts. Repair of thoracoabdominal aortic aneurysms (TAAAs) necessitated exposing the thoracic aorta above the diaphragm and the abdominal aorta below the diaphragm. Furthermore, these repairs were complicated by incorporating the branching visceral arteries, as well as the risk of life-threatening distal ischemia during repair. Although many of the early centers for aortic surgery were able to quickly develop aortic banks to prepare and store homografts, in time, it became clear that homografts were not ideal for aortic replacement. The ideal aortic replacement would be nontoxic, hypoallergenic, durable, elastic, pliable, and readily available in multiple sizes and shapes. Although Vinyon-N and other materials were explored as synthetic aortic substitutes, ultimately Dacron (Dacron, Kennesaw, GA, USA) was determined to be the most suitable material for aortic graft replacement. The success of Dacron ushered in extra-anatomic approach to TAAA repair, which remained popular for 2 decades. In time, the graft inclusion technique (which followed an anatomical approach) was adopted, which facilitated shorter repair times and improved outcomes for patients. rotective adjuncts-such as left heart bypass, cerebrospinal fluid drainage, and cold renal perfusion-were incorporated into surgical repair; the historical context of these adjuncts is explored in depth. The success of TAAA repair depends on the contributions of many individuals. The history of TAAA repair continues to evolve and remains indebted to the pioneering heroes, without whom, successful repair would not be possible.

Diagnosis and treatment of uncomplicated type B aortic dissection.

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25-40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.

Evolución terapéutica y controversias actuales en la cirugía de los aneurismas toracoabdominales / Therapeutic outcomes and current controversies in thoracoabdominal aneurysm surgery

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Deep hypothermic circulatory arrest: real-life suspended animation.

Deep hypothermic circulatory arrest (DHCA) is a cerebral protection technique that was developed in the 1950s and popularized in the 1970s. It has become one of the three most common cerebral protection techniques currently used in aortic arch surgeries, with the other two being antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). At our institution, DHCA has been the cerebral protection technique of choice for over a quarter century. Our clinical experience with DHCA has been very positive, and our clinical studies have shown DHCA to have outcomes equal to (and sometimes better than) those of ACP and RCP, and DHCA to be very effective at preserving neurocognitive function. Other institutions, however, prefer ACP or RCP to DHCA. Each technique has its own set of pros and cons, and the question regarding which technique is the superior method for cerebral protection is hotly debated.

Uncomplicated type B dissection: are there any indications for early intervention?

Currently thoracic endovascular repair (TEVAR) has a limited role in uncomplicated type B aortic dissection. Aggressive medical therapy is deemed appropriate for most of these patients allowing one-year survival rate of 80-90%. Outcomes are less than optimal in the long term, however, since aorta related complications (disease progression, rapid deterioration, acute rupture and elevated mortality) may occur in up to 50% of patients at five years. Subgroups of patients with uncomplicated type B dissection may benefit from early stent-graft placement, but identification of these remains difficult. Only future studies, especially randomized trials, will clarify the utility of early TEVAR in the setting of uncomplicated acute type B dissection.

The history of surgery of the thoracic aorta.

Until the late 19th century, treatment of thoracic aortic aneurysms relied on ligation of the parent vessel or introduction of foreign materials to promote coagulation or fibrosis. A major breakthrough occurred in 1888, when Rudolph Matas reported an internal repair technique known as endoaneurysmorrhaphy. In this approach, the clot was excised from the aneurysmal sac, and the orifices of the arteries that entered the sac were sutured from within, reestablishing continuous blood flow. At the beginning of the 20th century, Alexis Carrel and Charles Guthrie began to lay the foundation for modern vascular anastomotic techniques. Although isolated successes were reported, optimal treatment of thoracic aortic disease awaited the development of reliable synthetic grafts in the 1950s and 1960s. During the past 15 years, the treatment goal has reverted to endoaneurysmorrhaphy, involving the use of a suitable graft to restore aortic continuity.

Resection of aortic arch aneurysms using an external shunt.

Surgical treatment of aneurysms of the thoracic aorta had its beginnings in the early 1950s. At that time, thoracic aneurysms were usually due to syphilitic infection and were usually fatal. Before the development of the heart-lung machine, it was realized that external shunts could facilitate the repair of these aneurysms. In 1954, Dr Ralph Alley and his colleagues at Albany Medical Center reported 2 patients who had surgical correction of thoracic aortic aneurysms using external vascular shunts. Both bovine aortic heterograft and human aortic homograft were used as aortic substitutes. These patients were presented at the Thirty-fourth Annual Meeting of the American Association for Thoracic Surgery in Montreal, Quebec, in May 1954, and case reports were subsequently published in the Journal of Thoracic Surgery in 1955. These presentations served as the stimulus for subsequent clinical studies and laboratory research, eventually leading to a better understanding of the physiologic principles involved in clamping the thoracic aorta. Doctor Alley's article is a classic in the field of cardiothoracic surgery and is now reviewed 39 years after its publication.