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MEDISTATE HOSPITAL AORTIC SURGERY

AORTIC DISSECTION AND AORTIC ANEURYSMS


Definition


The aortic wall consists of 3 separate layers, which are called intima, media in the middle and adventitia on the outside. The medium layer consists of connective tissue containing dense elastic and collagen fibers carrying the main load and muscle bundles responsible for spasm formation. The blood in the heart is pumped into the aorta at each contraction of the heart; Aortic blood swells by stretching into the blood and when the heart loosens, the aortic valve closes and the blood in them continues to be pumped into the circulation due to the elasticity of all arteries. Since this stress and relaxation motion is a continuous and exhausting activity for the aorta and other arteries, it is particularly important to continuously renew the connective tissue within them; that is, on the one hand, the elongated break fibers must be removed and on the other hand reconstructed to withstand blood pressure and provide elasticity to the tissue. ,

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Aorta (drawing): The main artery (artery) that carries all the blood pumped from the heart to the body. Ascending Aorta at the exit from the heart, where it gives the arm and brain vessels arcus Aortic Arch (Descending) after the arc (Abdominal Aorta in the abdomen) and abdominal abdominal aorta (Abdominal Aorta) is the name of the abdominal arteries, then ends in the leg arteries. . Aortic wall section and formation on the right 3 layers: externally inward adventitia, Media and Intima.

Aorta (drawing): The main artery (artery) that carries all the blood pumped from the heart to the body. Ascending Aorta at the exit from the heart, where it gives the arm and brain vessels arcus Aortic Arch (Descending) after the arc (Abdominal Aorta in the abdomen) and abdominal abdominal aorta (Abdominal Aorta) is the name of the abdominal arteries, then ends in the leg arteries. . Aortic wall section and formation on the right 3 layers: externally inward adventitia, Media and Intima.

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Expansion and weakening create two threats: one of which is the rupture of the aorta from its weakest point, unable to withstand the pressure within the aorta. The other threat is that a superficial tear formed inside the aorta through the weakened media layer causes the blood to enter, causing the seyr single pipe inde in different parts of the aorta to lose, leading to multiple channels in which blood is observed. A flow of blood begins to form through a primary channel (true lumen) consisting of the adventitia and the part of the ruptured media forming the inner wall of the aorta, and a second channel (false lumen) formed by the adventitia forming the outer layer of the aorta and the torn media. Usually, these two channels are opened to each other in more than one region, resulting in multiple channel input and output; sometimes there is no other outlet from the entrance and this channel, which blood opens inside the aortic wall, coagulates (blind channel). We call this dangerous situation “dissection.. The dissection of the media tissue, which constitutes the main resistance, because the aorta is ruptured, as in the aneurysms is thin. Apart from tearing, another important complication in dissection is the risk of occlusion of the main arteries originating from the aorta. In such a case, coronary arteries with heart arteries, cerebral vessels and arteries leading to internal organs may become obstructed and the patient may experience fatal complications such as heart attacks, strokes, liver, kidneys, and intestinal damage.

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Frequency


Since the prenatal diagnosis of many cases cannot be established, the incidence of “real” dissection is not known. In the large autopsy series, it has been reported that the mortality rate is 3-10 per thousand. It is one of the important pathologies that cause “sudden death içinde among cardiovascular diseases. It is approximately 3 times more common in men than in women. The age range is very variable, we will discuss this again in the future.

Causes of the disease (etiology)


Hypertension: It is accepted as a factor that facilitates or triggers the formation, not the etiological factor. High blood pressure is associated with desection or aneurysm in 50-80% of patients with aneurysm or dissection.

Medial degenerative disease:

There are irregularities in collagen tissue in the aortic wall, rupture and deformation of elastic and collagen fibers, smooth muscle cell loss and cystic formations. Although the cause is unknown, familial transmission is known.

Genetically transmitted diseases:

Marfan syndrome: Fibrillin has a coding defect, its production is defective.

Ehlers Danlos Syndrome: Type III Collagen has a structural defect in the proa-1 chain.

Turner's disease, Annulo-Aortic ectasia and other familial dissections are also included.

Congenital cardiovascular diseases:

They usually amount to all aorta.

Bicuspid Aortic valve (normal Aortic valve consists of 3 leaflets; this disease involves birth with 2 leaflets; in fact, it does not cause any problems even in life, but in aortic stenosis, aortic valve insufficiency, aortic aneurysm or dissection is frequently involved. would).

Aortic coarctation The most common portion of the aorta after the exit of the left arm artery - the chest aorta from the human - is a severe constriction.

Atherosclerosis (arteriosclerosis):

In intima there is thickening, hardening, calcification as well as reduced cellular structure and degeneration of connective tissue fibers. As a result of these mechanisms, rupture often develops on the edge of the plaque and the blood divides the media layer into two by pressure within the aorta, sometimes forming dissection lines and false channels, sometimes reaching 1 meter. Although the cause of atherosclerosis is not known exactly, major risk factors such as high blood pressure, diabetes and familial transmission are known.

Inflammatory aortic diseases (arthritis - arteriosclerosis):

Inflammatory diseases cause damage to the media layer, causing weakening of the aortic wall. Takayasu's arteritis, giant cell arteritis, Behçet's disease, Rheumatoid Arthritis and Syphilis are some of the inflammatory diseases that show aortic involvement. The causes of these diseases have not been clearly elucidated, virus or intracellular bacterial infections or genetic transmission is blamed.

Trauma:

It occurs as a result of falling from a height or sudden deselation (hitting a standing object at high speed), almost all of which starts immediately after the left arm artery originates from the aorta (aortic isthmus).

(Iatrogenic) aortic injuries made by doctors:

Dissection may occur after coronary angiography, balloon angioplasty-stent, open heart surgery or as a result of orthopedic spine operations.

Drug addiction: Cocaine, amphetamine use are associated with dissection of the aorta.

Pregnancy: Dissection increased during pregnancy and is more common in eclampsia-preeclampsia cases.

Classification (Clinical Classification)


 Acute dissections: These are the first 14 days after the onset of symptoms. This process is the most life-threatening period. The newly formed dissection is often rupture or blockage of the organism leads to death.

 Subacute dissections: refers to cases seen within 14 days to 2 months.

 Chronic dissection: These cases are seen after 2 months.

Classification (Anatomical Classification by Location: - Most commonly used - De Bakey classification)


Type I: The closest to the heart (ascending) from the aorta to the leg arteries.

Type II: These are only dissections limited to the Ascadan aorta.

Type III A: A dissected aortic dissection in the chest extending from the end of the left arm artery to the diaphragm,

Type III B: Aortic dissection that spreads from the left arm artery to the abdominal aorta.

De Bakey (upper row type I-IIIb) and Stanford (lower row type A / B) type Aortic dissection classification.

Sizinle ilgili görüş ve referansları paylaşın

Müşterileriniz sizi sosyal medyada övüyor mu? Potansiyel müşterileri sadık müşterilere dönüştürmek için müşterilerinizin harika deneyimlerini paylaşın.

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Aorta adjacent to the heart; Asort Aortur. This region is in the pouch where the heart is located and is naturally the weakest Aortic region. Dissection and aneurysms exceeding 5.5 cm in diameter should be operated immediately. In case of rupture and bleeding, the patient is lost within a few minutes.

The region of the brain vessels is called the Arcus Aorta, which is operated in the same manner as the Aorta “emergency as. The next part is Desandan Aorta, if there is no rupture, it is operated non-urgently according to the Aortic diameter (max. 6 cm), the organs it threatens and the patient complaints. In the dissection and aneurysms of the descending thoracic and abdominal aorta, graft-covered stents can be placed instead of long and high complication operations.


Clinical symptoms:


During dissection, a “knife is stuck” or “tear-like” pain, as described by most patients. The patient often participates in kork fear of death gibi as in cold sweating and myocardial infarction. The tear of the aorta is almost generally felt in the area close to the pain. Mixed with heart pain in the anterior chest, mixed with lumbago or kidney stone in the back and lower back, Sudden Death: 50% of patients die at the time of the event, only 5-6% of the survivors can take out the first 30 days; early diagnosis and surgical intervention is the patient's only chance. Early intervention is very important, 1-3% of patients are lost per hour expected. Paralysis (due to arterial occlusion or embolism in the brain or spinal cord (5-10%). Heart failure (5%) is due to acute aortic valve insufficiency or coronary occlusion, often associated with dissection, shock due to blood loss. There may also be leg pain (20%), often on the left side, and renal or hepatic-splenic and intestinal (15%) arterial occlusions and associated pain and symptoms may occur.


Diagnosis:


If the patient's “preliminary diagnosis la can be made in the emergency unit, the diagnosis can be easily confirmed by Radiologically Contrast Computed Tomography (CT) and Echocardiography. Coronary angiography should not be performed in acute dissections, as it is insufficient to show false lumen and coagulation. It may be more useful in visualizing the side branches of the aorta, but may also create a risk of tearing due to the procedure. Therefore, coronary angiography should be performed only in chronic dissections that are not in critical condition or in the case of stagnant aneurysms followed “when a decision is made for surgery”.


Surgical Indications


If there is dissection in the Ascending Aorta or Arcus Aorta, an emergency operation is absolutely necessary. In the presence of aneurysm, if the patient has no complaints, the patient is monitored by computerized tomography at 6 months intervals until the diameter of the ascending or arcus aorta reaches 55 mm. If the descending aorta or abdominal aorta is 60 mm in diameter, or if the patient has pain, internal organs threatening, the patient should be intervened; computerized tomography. Although some patients do not enlarge for 10 years despite dissection, it can be seen that there is no risk of arterial obstruction that threatens the organs.


Surgical Strategy


The purpose of surgery in dissections should be to prevent aortic rupture and to restore the anatomy to its original state. The biggest problem here is that one cannot intervene with the “whole aorta la. Dissections often have problems with the entire aorta (de Bakey type I); to survive the vital condition by cutting the sternum from the anterior chest wall by cutting the sternum to the most important parts of the heart and aorta and most likely to rupture; that is, the Aort and the Arcus Aorta are intervened. Repair of the aortic valve is repaired if possible and the aortic valve is replaced if necessary. The coronary arteries, located just above the aortic valve, are prepared in the form of a button (boutton technique) and the aorta root - ascending Aorta is replaced by a tubular, synthetic fabric woven material (Dacron tube graft). If only this operation is to be performed and the arcus aorta is not to be intervened, the procedure can be performed by using a conventional heart-lung machine, cooling the patient to 26-28 degrees and without interrupting the circulation.

We call this operation “Boutton Bentall” operation in which coronary bouttons and aorta are replaced with aortic valve. Sometimes it is not necessary to transplant the coronary arteries to the top of the graft to be placed, then the ra supra coronary separe aortic graft ”is replaced by the aorta, not just the aortic root. Surgical operations where the valve is protected and root changes are performed. David operations, sometimes the coronary arteries can not be delivered to the graft in the anatomical structures of the coronary by connecting the graft to the aorta root replacement surgery is called Cabrol surgery. These surgeries are named after the surgeons who describe the technique and perform the procedure first.

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Boutton Bentall surgery on the left; Aorta + Aortic valve replacement from the ascending aorta with a uit composite gre graft (conduit) with aortic valve + suture of the right and left coronary arteries in the original anatomical positions (Boutton technique). Teflon feld (white color) is used to strengthen the tissue at the beginning of the arcus. David's surgery on the top right; Transplant the synthetic tube graft of the coronary arteries in the form of a aortic root + boutton to protect the aortic valve. At the bottom right; If it is not possible to suture the coronary bouttons in the natural anatomical position, thinner tube grafts are placed between them to provide coronary circulation (Cabrol technique), which is more beneficial in previous cardiac surgeries.


Aortic root replacement with David technique; original drawing (T. Oghus) Aortic valve preserved; Aortic root replacement after proper grafting of the Valsalva Sinuses and commissural areas (adjacent to the aortic valve). Coronary boutton sutures after root sutures are similar to the Bentall technique (the button shows the right coronary artery mouth as a button). The advantage of the David technique is to protect the patient from the disadvantages of the prosthetic valve in the long term by maintaining the patient's intact aortic valve.

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Bouttton Bentall technique: (Interventional photo: 2008- T. Oğuş). The air outlet on the graft was covered with a teflon-supported suture (black arrow); Non-coronary left coronary (NCC-LCC) commissure (white arrow). Right coronary boutton anastomosis is seen above the commissure (blue arrow). Completed surgery. The sutures used to attach the cap and graft to the heart cannot be seen because they remain deep, so if any bleeding occurs at this level or from where the coronary bouttons are sutured to the graft, it is extremely difficult to repair by placing additional sutures, making these sutures very carefully and never causing leakage. must.


AORTIC Rupture: (Intraoperative photo: 2006, T. Ogus). A case of aortic rupture starting from the right side of the patient to the aorta. The patient had no dissection and the aortic valve was intact. It is observed that the tear (white arrow) starts just above the level of the coronary arteries; Note the thinner structure of the aortic wall! The patient underwent separe graft insertion; extending the mouth of the graft to the NCC Aortic annulus where the tear begins to form in a tongue; Aortic replacement was performed from the ascending, the other RCC and the LCC “supracoroner ((David Modification).


Image after graft implantation in a patient undergoing supracoronary aortic replacement (David modification). Teflon support was not used in the suture line because the tissues were intact and both ends of the graft were sutured with continuous technique.

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Top left (drawing); Sinotubular junction; When a section is taken from the level where the aortic valve ends, the importance of whether the aortic diameter is enlarged is very large and this determines the shape of the operation. Aortic surgery does not require simple cutting and suturing, but an bir engineering account and a structural architecture ”. As aneurysm is often involved in the sinus valsalvae (the area where the valves are located), ascending aorta replacement with the Supra Coronary Separe graft is usually not possible. Above, the intraoperative view (2011- T. Oğuş) of a patient with anuloAortic ectasia on the right (photo) is presented. Pre-image: it can be seen from the outside that the fusiform aneurysm starts from the aortic root and the valve level joins the aneurysm; Aortic diameter at the valve level was measured 72 mm in preoperative measurements).

In cases where dissection or aneurysm is spread to the arcus aorta where the cerebral vessels come out, blood circulation must be stopped to replace the arcus aorta. For this purpose, the arterial connections of the heart-lung machine were obtained from the inguinal leg (Femoral Artery); or under the collarbone in the chest to the arm arteries (Axiller or subclavien artery). The venous blood in the heart is taken from the heart to the machine by another cannula, oxygenated and pumped through these arteries (extracorporeal circulation; ECC) and the whole body is cooled to 18-20 degrees. When this temperature is reached, circulation is stopped, body blood is taken out and the Arcus Aorta is visibly altered in the bloodless area.

At a temperature of 18-20 degrees, the tolerance of the brain to anemia increases significantly. When the blood circulation stops at normal temperature, brain cells begin to die in 3-5 minutes and a safe period of approximately 40-45 minutes occurs at temperatures of 18-20 degrees. If the surgeon is able to change the Arcus Aorta during this time, no additional procedure is required for the patient. We call this method Total Circulatory Arrest (TSA). Sometimes the dissection lines reach inside the brain vessels and eliminate these torn lines, you need to put small tube grafts individually for each brain vessel. If he thinks that this cannot be done within 40-45 minutes:

The surgeon connects each of the two main cerebral vessels to the pump individually (individual cannulation) and pumps blood from there to ensure that the brain cells are not damaged in the elapsed time.

It delivers oxygenated blood from the vein system of the brain to the brain and minimizes cell oxygen and energy requirements with a reduced blood flow (retrograde cerebral perfusion).

In this way, either “peninsula” (Koutchoukos technique) or tamamen island ”change of arcus Aorta (Elephant trunk) is done. After the replacement of the arcus, blood from the groin artery or arm artery is removed and the air in the synthetic vessel in the renewed aorta is removed. During this period, necessary surgical corrections are made for the aortic root adjacent to the heart and the aorta. After the procedure is finished, the grafts in the aorta of the arcus and the aorta are sewn together.


Schematic Arcus Aorta replacement. A-incision; B-Synthetic graft is inverted and placed 4-5 cm at the end of the graft.

Visually suturing the graft at the end of the aortic aorta

Retracting the folded portion of the graft towards the arch (A); the shape of the graft from the descent at the aortic onset (B). The arm and brain vessels coming out of the arcus have been transferred to the graft. If an intervention is required from the thoracic descending aorta to the patient at a later time, the intact graft tip will be of great benefit to the patient.

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Arcus Aortic Replacement by Elephant trunk (Elephant tube) technique: In the above drawing, the arcus aneurysm and aortotomy incision are schematized. Patient After connecting the heart-lung machine and taking over the circulation, cooling to 18 degrees, total circulatory arrest is entered. The arcus is opened and the thoracic (from the descendant) is placed in the olmayan non-aneurysmatic, farthest, most accessible part A of the aorta by inverting the graft as shown in the figure, with a length of about 3-4 cm at its end, sutured to this region, and then the graft is pulled out towards the arcus. After this stage, Arcus Aorta will be prepared in the form of an island and transferred directly to the graft. These sutures can usually be finished in 25-30 minutes and the circulation is restarted without damaging the patient's brain.

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Schematic drawing. Preparation of the brain and arms of the island-shaped aortic aorta (left-to-right brachiocephalic artery (right arm and right main brain artery), left carotid community (left main brain artery), left subclavien artery (left arm artery) in the drawing; (B) At the end of the procedure, the arcus elements are sewn into a whole island opening in the appropriate size (C).


Arcus exchange with graft prepared as peninsula by Koutchoukos technique. It was sutured end-to-end with a graft used for aortic root replacement near the heart. Since the aneurysmatic part of the Arcus Aorta is only the lower part, only this region is replaced.

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Arcus Aorta + Ascending Aorta + Boutton Coronary Transfer + Aortic Valve Replacement: Intraoperative photo (2013- T. Oğuş): De Bakey Type I A hast elephant trunk yapılmış replacement was performed in a patient with dissection; After removal of the air, a synthetic graft (blue arrow) was placed on the cross clamp (XC) (yellow arrow) and extracorporeal circulation was resumed from the femoral artery. Aortic valve defect in the aortic root was removed; For valve replacement aortic root replacement (Boutton Bentall), coronary ostia are prepared as buttons (boutton). Yellow intense cholesterol plaques (black arrows) are seen on the inner wall of the aorta. Pathological examination of the patient revealed atherosclerosis as the cause of dissection.



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Iatrogenic DeBakey type I Aortic dissection: Intraoperative photograph, a redo case who had previously undergone cardiac surgery (2005, T.Oğuş). Arcus Aortu was replaced by Elephant trunk method and circulation was started and heating was started. Aortic root was changed by Cabrol technique without valve replacement. Because the patient's coronary anatomy was not convenient, both coronary arteries were connected to each other by an 8 mm PTFE reinforced tube graft (yellow arrow). it is provided. Both grafts at the aortic root and aortic root are sutured to each other and the operation is terminated and the heart is circulated.

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langed Boutton Bentall technique; Modification of Cevat Yakut (original drawing T. Oghus). The appropriate size of the graft, the appropriate size of the cover graft is made into a composite graft "hand made conduit" of the aortic root (heart exit) sewn. Since 1998, we have been performing Bentall operations with this modification. The 4 mm graft residue under the cover gives the composite graft flexibility to the heart at the site of attachment. After this procedure is completed, the left main coronary (because it remains behind) and then the right coronary transplantation will be performed on the graft.


SURGICAL CORRECTION OF THORACOABDOMINAL ANEURYSM AND DISSECTIONS


There are 3 kinds of operation methods; the work is the same; to remove the diseased segment and to insert a tubular synthetic vessel to maintain the aorta. In the meantime, it may be necessary to transplant the spinal cord artery, which is located between the thoracic vertebrae 8-12, to this graft. The surgeon predicts how long this work can be completed and draws the surgical strategy accordingly.

Clamp and go !. A direct cross-clamp is placed in the aorta to repair rapidly. In this technique, when the aorta is clamped, the blood flow under the clamp is cut off or the blood flow continues only with the anatomical bridge veins which we call collateral. If the procedure can be performed quickly, this technique is the most tolerable technique for the patient. However, the loss of blood due to bleeding is high and at least some of this blood to be able to take back to the body "cell saver" is necessary to use an expensive device called.

Passive aorta-femoral shunts: The blood taken from the ascending aorta through a cannula is delivered to the patient through the groin artery below its own pressure. When clamp is applied to the diseased area, it allows feeding of the abdominal organs and spinal cord below.

Applying aortic perfusion with the help of atriofemoral bypass (in this case, oxygenated blood is pumped through a cannula placed in the left atrium and pumped through the groin artery to the patient. In this way, the sites beyond the clamp location (spinal artery, kidney, liver bowel arteries) are drawn from the lower side. Ischemia. Hasta The patient is exposed to a number of complications related to the use of the heart-lung machine, the most important of which are lung, renal failure and bleeding, and the clot formation in the patient is not desired. .

Cooling the patient under femorofemoral bypass (femoral artery + vein cannulation and ECC) and performing repair under total circulatory arrest. It is similar to the surgery of the Arcus Aorta, and the patient is exposed to all side effects of the heart lung pump and deep cooling.

In chronic dissection, it is not sufficient to apply the method of acute dissection to patients with aneurysmal dilatation; it is necessary to continue to deliver blood into both the true and false channels (lumens); because there may be critical internal organs fed from the false lumen. For this purpose, by cutting the wedge (triangular) dissection flap at the end of the graft, the flow from the graft should be delivered to both the actual and the false lumen. This leads to the risk of subsequent aneurysm development in lower aortic segments.


Results


Despite all improvements, mortality is still high (5-25%). The operations for thoracic and abdominal aortic dissection and aneurysms are the largest operations of cardiac surgery, as in Asandan and Arkus Aortic surgery. As technology advances, surgical and interventional stenting (EVAR / TEVAR) will be applied together to significantly reduce mortality and complications.

Complications (early period)

Paraparesis and paraplegia, Acute renal failure, Respiratory failure, Gastrointestinal complications, coagulopathies.


Complications (late term)

Development of pseudoaneurysm, Graft thrombosis, Graft infection, Aorto-enteric fistula, Aorto-caval fistula.


Results


(* According to Svenson and Crawford series)

Hospital mortality: 10%,

Paraparesis / paraplegia: (paralysis of both legs) 16%, (Type II: 35%)

Development of renal failure (half requires dialysis). 18%,

Pulmonary complications, respiratory failure, machine support: 33%

Severe, life-threatening infections: 8%

Postoperative bleeding-coagulation disorders: 4%

As can be seen, the complication rate is extremely high and considering the fact that the patients are older, the cause of the high mortality seen in the classical operations of thoracoabdominal aortic aneurysm or dissection will be immediately understood.


Endovascular Treatment of Thoracic / Thoracoabdominal / Abdominal Aortic Aneurysms and Dissections (EVAR)


Unsatisfactory results with classical surgical methods, new and easier techniques to develop thoracoabdominal aortic aneurysms and dissections in humans have developed


EVAR / TEVAR Complications


Paraplegia: 0-4%. It is seen less frequently than surgeries.

Renal insufficiency: It is caused by contrast agents which are commonly used in complicated cases (angiography is used for image acquisition), but it does not require as much dialysis as the patients undergoing surgery.

Paralysis: It often occurs during the movement of the guide wire and catheter in the arch region. It is due to the removal of the clot or atheroma plaque from this region and embolization of an artery at the far end.

Respiratory failure: When triggered by anesthesia due to frequent lung disease, obvious respiratory failure may occur; epidural / spinal anesthesia may be used as an alternative in such patients.

Heart Attack: Coronary artery disease is frequently involved in thoracic and abdominal aortic aneurysms and occurs because there is no time to investigate because of the urgency of the case.

Peripheral embolization: Breaking clot or atheroma plaques are dragged by blood flow, occluding an artery in front of it. Bowel embolism and kidney embolism are the most common.

Pulmonary embolism: It may be in the postoperative period of every elderly patient. For this purpose, blood thinners / injections are given to the patient after surgery.

Wound infection: It is seen at the rate that it may occur in every surgical intervention.

Thrombosis of the stent-graft: Although not very common; It occurs as a result of compression or curl of the graft in the upper or lower border.

Graft migration: As a result of the replacement of the graft with the blood flow, it makes the aneurysm entry that should be closed open again to the blood flow.

Endoleak: A blood filled-leakage into the aneurysm sac as a result of the graft not fitting to the neck of the aneurysm.

Graft infection may also occur. The rate of graft infection is much lower (<1%) than the patients who underwent open surgery, the most important reason being that the graft does not remain outside for hours and is not manipulated.


Advantages of Endovascular Therapy Compared to Classical Aneurysm Surgery


The procedure time is significantly shorter in EVAR / TEVAR interventions, less incision in the patient, less traumatization, and less blood loss, resulting in a significantly shorter postoperative recovery: the complication rate is much lower, and mortality is significantly reduced (<1% globally). More and more technology is advancing in this field and “thoracic and abdominal aortic aneurysms tarafından, which are difficult to overcome successfully by both patients and surgeons, are being replaced by ENDOVASCULAR STENT procedures.


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Thoracic (thoracic) EndoVascular Aortic Aneurysm Stented graft Replacement (TEVAR); As shown in the drawing, the Left Arm artery (Arcus Aorta is the 3rd artery; in our opinion, on the right; if you look at the patient, of course, the yellow arrow on the left) is not excluded. If necessary, the left arm artery can be closed by exclusion of the circulation and the arm feeding is often not interrupted by the extensive collateral network. In this case, circulation of the ancreas at the tip of the graft (= anchor; metal assembly that secures the graft to the vessel) continues. Circulating intercostal arteries in the aneurysm sac are closed for a while and the blood clots here, leaving the aneurysm that is in danger of tearing.

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Endovascular stent-mounted graft combined with open heart circulation and Total Circulatory Arrest in the operating room environment, aortic replacement (EVAR) and additional surgical procedures (ASAR + arcus + decane) may make the operation easier and less risky. It should be noted that the arcus elements are individually attached to the ascending / new arcus aorta by tube grafts. It has not yet become widespread in our country.

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Exclusion of the aortic aneurysm with a stent-mounted graft in the infrarenal abdominal aortic aneurysm: Both groin surgically open to the femoral arteries. First, the main body (the main body sitting in the aorta and a leg-main graft sitting in the iliac artery) is placed in place within the aneurysm (in this case it is placed on the patient's right; it can also be placed on the left). The other leg graft is then inserted from the opposite side into the half leg; If there is no leakage at the entry and exit points (confirmed by angiography at the end of the procedure), aneurysm exclusion and distal perfusion are complete). The procedure time is usually related to whether the iliac arteries are too angled or undulated (can be completed in approximately 1.5 hours). As the angles change, it becomes difficult to snap the graft into place.

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An example of stent grafts used in abdominal aortic aneurysms: Figure on the left: A: An image of the stent opened in the outside. B: Approximate image: Stent opened out; a special ancre mechanism (= anchor) developed for suprarenal fit and migration. One feature of this graft is that it contains hollow holes at the level of the Superior mesenteric Artery (intestinal artery) and Renal arteries (renal arteries); After the trunk was seated, thinner stented grafts were also placed in both renal arteries. Figure on the right: The graft structure at the level of superior mesenteric and renal arteries is seen in more detail. There is a notch at the mouth of the Superior Mesenteric Artery; instead, the hole is passed through another stented graft through the Superior Mesenteric Artery or above it Coeliac Artere 3.-4. Grafts can be placed. After the clinical safety and practice of these stents become widespread, we believe that open surgery and thoracic and abdominal aortic operations will end.