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Aortic Aneurysm. Classification of Aortic Aneurysm (According to Location) Ascending Aortic Aneurysm(Annuloaortic ectasia Aortic Arch aneurysm Descending Aortic Aneurysm Thoracoabdominal Aortic Aneurysm Abdominal aortic Aneurysm Shape of Aneurysm * Sacuclar type * Fusiform type

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Aortic Aneurysm

  • Classification of Aortic Aneurysm

  • (According to Location)

  • Ascending Aortic Aneurysm(Annuloaortic ectasia

  • Aortic Arch aneurysm

  • Descending Aortic Aneurysm

  • Thoracoabdominal Aortic Aneurysm

  • Abdominal aortic Aneurysm

  • Shape of Aneurysm

  • * Sacuclar type

  • * Fusiform type

  • * Dissecting aortic aneurysm

Etiologic Classification

  • Congenital aneurysm

  • Acquired aneurysm

  • * Atherosclerotic aneurysm

  • * Traumatic aneurysm

  • * Syphilitic aneurysm

  • * Mycotic aneurysm

  • * Dissecting aneurysm

Thoracic Aortic Aneurysm

Indication for operation

Ascending Aneurysm

* Progressive enlargement of the aneurysm(5-6 cm)

* Signs and symptomes of aortic valvular regurgitation

(Bentall procedure)

Transverse Aneurysm

* Symptoms(dyspnea,stridor,hoarseness,hemoptysis,cough, and chest


* In the fusiform medial degenerative type,diameter > 5cm

Descending Aneurysm

* All symptomatic patients

* diameter is twice that of the normal aorta(around 6 cm)

* Acute enlargement

Thoracoabdominal Aortic Aneurysm

Crawford Classification

Type I : Aneurysms involve all or most of the descending

thoracic aorta and suprarenal abdominal aorta

Type II : Aneurysms involve all or most of the descending

thoracic aorta and all or most of the abdominal aorta

Type III :Aneurysms involve distal half or less of the

descending thoracic aorta and varying segments of the

abdominal aorta

Type IV: Aneurysms involve all or most of the abdominal


Clinical Symptomes and Sign of the Dissecting Aortic Aneurysm

Aortic Dissection

Splitting of the medial layer of the

Aortic wall,associated with intimal

Flap---Inlet—develope false and true


Aortic Dissections Classification

Stanford Classification

Type A: Dissection involving the ascending aorta

Type B: Dissection involving the descending aorta

DeBakey Classification

Type I: An intimal tear,commonly located in the

anterior ascending aorta and progressing through the

arch into the descending aorta,whole abdominal aorta

Type II: Dissections are confied to the ascending aorta

Type III: Involving only the descending aorta(Type IIIa:

,Restricted to the thoracic aorta. TypeIIIb: involving

in abdominal aorta and extending distally)

Clinical Presentation and Diagnosis

Hemodynamic State

*Sudden death *Hypovolemic shock

*Cardiogenic shock(acute AR 35-60%)

Symptomes and Signs

* Sudden severe pain and feeling of impending death

(Often interscapular pain,precordial and radiate into

neck or arm)

* Painless * Ischemic sypmtomes of occlusion of a major



1. Chest x-ray

2. Ecchocardiography

3. CT scan

4. Aortography or MRA

Surgical Indication of Dissecting aortic Aneurysm

Type A---

Indication is made once diagnosis has been

confirmed and the patient can be stabilized

with drugs therapy

Type B---

1. Progress of dissection process

2. Impending rupture of dissecting aneurysm

3. Poor control of BP and pain persists or

progesses to the abdomen under intensive


4.Organ or limb ischemia,neurologic sign with

paresis or paralysis

The Major Risk Factors for Aortic Reconstruction

* Adequate cerebral protection

* Bleeding coagulopathy

* Protection of the ischemic myocardium

Advance Improvement in Aortic Reconstruction

* Graft technique

* Anastomotic technique

* Use of echocardiography

* Improved hemotology

* Myocarial and cerebral protection


1.Profound Deep Hypothemia

Central Temperature :16-18 *C

2. Deep Hypothemia

Central Temperature: 18-20 *C

3. Moderate Hypothemia

Central Temperature: 26-28 *C

+ Separate Carotid Blood Perfusion

4. Deep or Moderate Hypothemia

Central Temperature: 20-23 *C

+ Retrograde SVC Blood Perfusion

Abdominal Aortic Aneurysm

Rupture Risk of AAA

Rupture rate per year

Less than 4 cm diameter 0%

4-5 cm diameter 0.5-5%

5-6 cm diameter 3-15%

6-7 cm diameter 10-20%

7-8 cm diameter 20-40%

More than 8 cm diameter 30-50%

The Confirm Diagnosis for A.A.A.

  • Regularly physical check up

  • Ultrasound

  • CT scan

    3mm-5mm interval, 3-D reconstruction

  • Angiographies

  • MRI

Symptoms for A.A.A.

  • Usually a symptomatic

  • Incidental finding

  • Palpable mass in mid abdomen

  • Back pain

  • Abdominal fullness, abdominal pain

Postoperative Complications of Aneurysmectomy of the AAA

  • Bleeding

  • Infection

  • Rupture

  • False Aneurysm

  • Change in Sexual Function

  • Spinal Ischemia

Ischemic Colitis Following Aortic Reconstruction

  • Ligation of IMA(improper)

  • Loss of IMA-hypogastric blood flow

  • Rupture aneurysm

  • Perioperation hypotension-hypoperfusion

  • Manipulative trauma

  • Inadequate collateral development

  • IMA SMA flow in meandering mesenteric

Criteria for Endovascular Treatment

  • Maximum angulation of the neck <60 degree

  • Grade I,IIA,IIB,infrarenal neck length >1.5 cm

  • Proximal aortic neck diameter <28 mm

  • Common iliac diameter < 20 mm

  • No thrombus lined or calcified aortic neck

Indications for Endovascular Treatment of Aortic Aneurysm

  • Asymptomatic AAA more then 5 cm in diameter

  • All symptomatic or rupture aneurysm

  • High risk patient and unfit for conventional

    open repair

  • Older patients ,even an AAA less than 4 cm in diameter

Types of Aneurysm for A.A.A.

Contra Indication for Endovascular Treatment

  • Short neck <10mm

  • Wide angle >75°

  • Conical neck 3mm/10mm

  • Calcified or thrombus surround the neck

  • Torturous iliac artery>90°

  • Calcified iliac artery

  • Iliac aneurysm

  • Short iliac artery

Potential Adverse Events of Endovascular Repair

  • Death

  • Emboli and subsequent tissue damage or loss

  • Perforation of aorta

  • Hypotension

  • Pseudoaneurysm at the vascular access site

  • Infection and pain

  • Contrast reaction

  • Vessel damage

  • Iliac stenosis

  • Myocardial infarction

  • Bowel ischemia

  • Claudication

  • Renal complications

The Procedures and Tips for Placing Endovascular Stent Graft

Follow up for the Endovascular Stent Graft Procedure

  • Graft migration

  • EndoleakI. Neck,iliac II. Retrograde flow III. Device failureIV. Porosity

  • Kinking of graft

  • Size of the sac

Other Complications

  • Injury to artery

  • Embolization

  • * Postimplant syndrome

  • Graft limb thrombosis

  • Groin wound infection

  • Conversion to open repair

  • Aortic rupture

  • Endograft migration obstruction

  • Persistent endoleak

  • Endograft infectin

Future Trend for the Endovascular Procedure

  • Overcome present difficulties

  • Ruptured A.A.A.

  • Aortic dissection

  • Thoracic aneurysm or aneurysm in other sites

  • Surgical treatment of the Ischemic heart disease

  • Clinical symptome , diagnosis and treatment of aortic dissection

  • Surgical treatment of the aortic disease

  • Pathophysiology of pulmonary hypertension

  • Clinical symptoms and signs of pulmonary embolism

  • Management of pulmonary embolism

  • Clinical symptoms,signs and diagnosis of peripheral vascular disease

  • Medical and surgical treatment of the peripheral vascular disease

Surgical Treatment of the Ischemic Heart Disease

Major Clinic Presentations of Ischemic Heart Disease

  • Stable angina pectoris

  • Unstable angina pectoris

  • Acute myocardial infarction

  • Less commnon presentations:

  • * Silent ischemia

  • * Sudden death

  • * Arrhythmia

  • * Congestive heart failure

  • * Papillary muscle dysfunction with MR

Risk factore for operative morbidity and mortality in CABG surgery

  • Age above 70(1.5-2 fold increase in mortality rate)

  • Left ventricular dysfunction(2-3 fold increase)

  • Female gender(1.2-1.5 fold increase)

  • Previous CABG operation(2.5-3.5 fold increase)

  • Diabetes mellitus(1.2-1.5 fold increase)

  • Peripheral vascular disease(1.2-1.5 fold increase)

  • Chronic renal failure(1.5-1.9 fold increase)

    Main operative morbidity

    * Cerebrovascular accident (2%)

    * MI (3%)

    * Mediastinitis(1%)

Conduits for CABG

  • Greater saphenous vein

  • Lesser saphenous vein

  • Left and right internal mammary arteries

  • Radial artery

  • Right gastroepiploic artery

  • Inferior epigastric artery


* Saphenous Vein Grafts

* Internal Mammary Artery Grafts

Alternate Conduits

* Gastroepiploic Artery

* Inferior Epigastric Artery

* Radial Artery

* Cryopreserved Homograft Veins

Surgical Indications for coronary artery bypass grafting

  • Unstable angina

  • Left Main CAD

  • Symptomatic tree vessel(TVD) with Failure of medical therapy

  • depressed LV function

  • Postinfarction angina

  • Acute myocardial infarction with cardiogenic shock

  • Failure PTCA or stent

  • Reoperation for recurrent symptomes

  • Congenital anomalies of coronary arteries

  • Kawasaki’s disease

Indications for insertion of an intraaortic balloon pump (IABP) in acute coronary events

  • Inadequate response to medical therapy(resistent pain or EKG change)

  • Failure angioplasty with hemodynamic unstability

  • Preoperative evidence of significant myocardial injury or hemodynamic instability

  • Marked ST-T changes during anesthetic induction for CABG

Incremental Risk Factors for Premature Death After CABG

* Number of vessels with important stenoses

* Preoperative poor left ventricular function

* Chronic congestive heart failure

* Unstable angina

* Emergency surgery for acute infarction with

hemodynamic compromise

* Older age

Acute Ischemia

Medical therapy to stabilize

Unstable Stable

Mechanical defect Ischemia Functional Cardiac

study catheterization

VSD MR Free wall Ischemia No ischemia


Cardiac catheterization

Consider open surgery

Indications for Cardiac Operation in Patients with Acute MI

  • Mechanical complications after MI(papillary muscle rupture with acute MR,postinfarction ventricular septal defect or free wall rupture,left ventricular aneurysm)

  • Cardiogenic shock after MI

  • Evdence of MI extension(continued symptomes,EKG

    changes,additional elevation of cardiac enzymes)

  • CABG or PTCA for evolving MI(During the first 4-6 hous after MI), acute complications of PTCA,or stent

  • Unstable angina with failure of medical management

  • Severe left main coronary artery stenosis

Postinfaction ventricular septal defect

Timing of Operation

* Waiting for several weeks--Small minority

of patient,the hemodynamic insult is less

severe and better tolerated

* Prompt operation--Persistence of congestive

heart failure with low cardiac output

# Shortening the duration of shock by operation

early is the only therapeutic solution and yield

dramatic results

Postinfaction ventricular septal rupture


* Overall hospital mortality of 10-25%

Sander RJ ,Skillington et al,Dagget WN et al.

(1975-1989 report)

Correction of posterior defect 24-32%

Closure of anterior defect 12-15%

Postinfaction ventricular septal rupture

Preoperative therapy

Stabilization of the hemodynamic condition

50-60% present with severe congestive heart

failure and a low cardiac output

* Reduce the systemic vascular resistance

* Maintain cardiac output and arterial pressure

* Maintain or improve coronary artery bloodflow

Surgical Treatment of Left Ventricular Aneurysm

Incidence and nature history

10-35% aneurysm dilatation of the LV

occures in transmural MI

Variable motality rates without operation

73% less than 3 years

88% less than 5 years Schlicher et al.

53% at 5 years

88% at 10 years Proudfit et al


* LV dysfunction

* Mural thrombus

* Ventricular arrhythmias

* Ventricular rupture

* Mitral insufficiency

Surgical Treatment of Left Ventricular Aneurysm

  • Plication of LV Aneurysm

  • Aneurysmectomy with linea repair of LV aneurysm

  • Endoventricular patch plasty reconstruction

  • Dor’s Operation





LV aneurysm or wall motion abnormalities

Permanent cardiac failure,NYHA III-IV

Clinical criteria

Dilated failing ventricle(DFV) or LVWA

EF <30%,mean PAP >25 mmHg,

LV circumference asynergy >60%

LVEDV >250 ml(LDVI >140ml)



Dor’s operation for treatment LV aneurysm





* CABG before left ventricular reconstruction(LVR)

* Left atrial or ventricular approach for repair MR

* Crytherapy or subtotal endocardectomy for ventri-

cular arrhythmia

* Endoventricular circular suture 1-2 cm above sound

muscle(put inflated balloon in the ventricular cavity

,diastolic volume of 50-70 ml/m2),cannot be directly

suture the revascularied LAD area.

* Septal exclusion,folded on the patch.

Coronary Reoperations

* Up to 15% of revascularization today

* The risk of coronary revascularization is

higher than for first operation

3-4 times risk of death

2 times risk of stroke

8 times risk of perioperative MI

Combined Coronary

and Carotid Artery Disease

* Evaluation of the patients

* Etiology of cerebral injury

during CABG

* Operative strategy



Hazards of Extracoporeal Circulation

  • Stroke and neurologic defect

  • Immunosuppression

  • Systemic inflamatory response

    1. Bleeding complications

    2. Renal insufficiency

    3. Pulmonary insufficiency

Current Technique for Coronary Artery Bypass Surgery

A. Off-pump coronary bypass via complete sternotomy

B. MIDCAB via a small incision

“ Off-pump” or “On-pump”

C. Port-access techniques




Outcome “Off Pump” CABG

  • Shorter postoperative ICU,hospital stay

  • Shorter time with ventilatory support

  • Less blood loss , less or no blood transfusion

  • No aortic manipulation

  • Reduce systemic inflammatory response

  • Less neurologic postoperative complications

  • Improved cosmesis

  • Return to normal activity soon and quicker patient recovery

  • Reduced cost

Advantage of MIDCAB for Redo Patient

  • * Minimized manipulation of the grafts and

  • dissection of adhesion,avoid injury patent

  • graft,heart and greater vessels

  • *Avoid stabilizer for stabilization for CABG

  • * Shorter hospital and ICU stay

  • * Different approach to target coronary

Endoscopic Saphenous Vein Harvesting

  • Minimally invasive technique(Removal the entire vein through a single or two 1.5 cm skin incision)

  • Decrease incision length

  • Earlier ambulation,allowint immediate cardiac rehabilitation

  • Decrease incidence of wound infection and dehiscence

  • Improved cosmetic appearance

  • Decrease pain of venous harvest region


Transmyocardial Revascularization

The process of creating channels through the wall of the left ventricle which allows oxygen rich blood from within the left ventricle to perfuse out into the ischemic area of the myocardium.

TMR Sole Therapy Procedure

UsingThe Heart LaserTM System

  • Beating Heart

  • Left Thoracotomy

  • General Anesthesia

  • ~ 90 Minute Procedure

  • 30 Day Mortality of 1%

Left Ventricle


Laser Holes

CO2 Laser

Perfusion Defect

Bypass Graft

Left Ventricle

Diffuse Disease

C02 Laser

Perfusion Defect

(Untreatable with bypass graft / PTCA)


TMR in Combination with CABG

Pathophysiology of Pulmonary Hypertension

Etiologies of Pulmonary Hypertension

1. Primary pulmonary hypertension

2. Secondary pulmonary hypertension

A. Cardiac disease

1. Congenital heart disease

2. Acquired heart disease

B. Pulmonary disease

1. Chronic obstructive airway disease

2. Chronic interstitial disease

3. Pulmonary vascular disease

C. Disorders leading to aveolar hypoventilation

3. Pulmonary veno-occlusive disease

Clinical symptomes and Signs of Pulmonary Embolism

Stasis Vessels Injury Hypercoagulable


Deep Vein Thrombosis

Pulmonary Embolism Postphlebitis symdrome

Clinical Symptoms of Pulmonary Embolism

Masive pulmonary embolism

Syncope,profound dyspnea,cor pulmonale

cardiogenic shock,cardiac arrest

Submassive pulmonary embolism

Chest pai,tachypnea,dyspnea

Pulmonary infaction

Hemoptysis,chest pain,dyspnea

Management of Pulmonary Embolism

Pulmonary Embolism Suspected

Clinical symptoms and signs(+)

Stable condition Unstable condition

Ventilation-perfusion scan Pulmonary angiography

Negative Positive Equivocal or positive


Unstable Thrombolytic agents Contraindication

(Pulmonary embolectomy) Heparin (Inferior Vena Caval

Coumadin Clip or filter)

Diagnosis and Treatment of the Peripheral Arterial Occlusive Disease

Cause of Peripheral Arterial Occlusive Disease (PAOD)

  • Arteriosclerosis

  • Thromboangitis obliterans(Buerger’s disease)

  • Angitis of other origin

  • Fibromuscular dysplasia

  • Posttraumatic occlusion

  • Raynaud syndromes

  • Postembolic occlusion

  • Congenital stenosis,atresia, or aplasia

  • External compression syndromes

  • Arterivenous fistula

Exclusion of other painful condition of the lower limb

  • Lumbosacral root irritation

  • Osteroarthritis of hip and knee joint

  • Venous insufficiency

  • Peripheral neuritis

  • Glomus tumor of the foot

  • Other musculoskeletal system disease

Fontaine Classification of Peripheral Arterial Occlusive Disease

  • Sense of cold,numbness,Raynaud’s syndromes

  • Intermittent claudication

  • Rest pain

  • Ulcer,gangrene

Physical Examination

  • Inspection

  • a. Trophic change

  • b. Color change

  • c. Ischemic ulcer

  • d. Gangrene

  • Palpation

  • a. Temperature

  • b. Pulse

  • 3. Auscultation : Bruit

Noninvasive Vascular Laboratory Examination

  • Doppler arterial signal analysis

  • Resting ankle blood pressure

  • Doppler segmental limb pressure measurement

  • (Three or four segmental)

  • Hyperemia test

  • a. Treadmill exercise testing

  • b. Reative hyperemia test

  • Pulse volume recorder

  • Strain-gauge plethysmography

  • Photoplethysmography

Principle of the Treatment

  • General measure

  • a. Total cession of smoking

  • b. Exercise and decrease body weight

  • c. Drugs therapy

  • 2. Mechanical revascularization treatment

  • a. Vascular reconstruction

  • Endarterectomy

  • Bypass grafts

  • Sympathectomy

  • b. Balloon angioplasty(PTA) or stent

  • c. Aterectomy(TEC,Kensey,Simpson)

Aortoiliac and Aortoiliacfemoral Reconstruction

Direct Aortofemoral Unilateral byass

(Aortoiliac) Bilateral bifucation

“Y” graft

Aortoiliac endarterectomy

Transluminal angioplasty(PTA) or stent

Indirect Axillofemoral bypass graft

Transpubic femorofemoral crossover graft

Femoral-popliteal-tibial Reconstruction

a. Thromboendarterectomy

b. Supragenicular

Femoropopliteal bypass graft


c. Femoral tibial bypass graft

d. Femoal peroneal byass graft

(Reverse or In-situ saphenous vein graft,GorTex graft)

Associated procedure:


Transluminal angioplasty or stent

Lumbar sympathectomy

Acute Limb Ischemia


Metabolic syndrome and reperfusion injury

Clinical classification

I. Viable

II. Threatened

a. Marginally

b. Immediately

III. Irreversible

Clinical diagnosis ( Five P’s)

Pain,pulselessness,pallor,paresthesia and paralysis

Etiology of Acute Limb Ischemia

1.Embolic Occlusion

Origin of arterial emboli

* Arterial fibrillation

* Rheumatic MS(90% from heart)

* Myocardial infarction

Less common causes

* Debris from aneurysm * Prosthetic heart valves

* Debris from ateriosclerotic plaques

* Left atrial myxoma * Ventricular aneurysm

* Bacterial endocarditis * other

2.Acute Arterial Thromboembolism

3.Bypass Graft Thrombosis

4. Other

Treatment of Acute Limb Ischemia

Early diagnosis Late diagnosis

Immediate Heparin Thrombolytic


Arteriography Amputation

Emergent Catheter

Thromboenbolectomy Vascular Amputation


Extracranial Cerebrovacular Disease

  • Diagnostic Method

  • Dopscan

  • Gee-OPG

  • Carotid angiography

  • MRA

  • Bidirectional Doppler

  • CT scan

Extracranial Cerebrovascular Disease

Proven indication

* One or more TIA in last 6 months and a carotid stenosis

greater than or equal 70%

* Mild strokd with carotid stenosis greater than or equal to



* TIAs in past 6 months and a stenosis 50-69%

* Progressive stroke and stenosis greater than or equal 70%

* Mild or moderate stroke in past 6 months and a stenosis

50 to 69%

* Carotid endarterectomy ipsilateral to TIAs and a stenosis

greater than or equal 70%,combined with required CABG

* Asymptomatic carotid ulcerated lesion

* Asymptomatic contralateral carotid artery stenosis

* Subclavian steal syndrome

Extracranial Cerebrovascular Disease

Contraindications to Carotid Surgery

General * Severe hypertension

* Myocardial disease

* Advanced biological age

Local * Simultaneous bilateral carotiendarterectomy

* ICA siphon stenosis

* Combined extra- and intracraniacarotid lesion

Neurological * Within 4 weeks of frank stroke

* Stroke in evolution

* Acute profound stroke

* Cerebral infaction with dense hemiplegia

  • Extracranial Cerebrovascular Disease

  • Operation

  • Carotid endarterectomy

  • Bypass surgery

  • Extranatomic bypass graft

  • Direct interposition

  • Patch angioplasty

  • Transluminal angioplasty

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