Aortic Valve Preservation and Repair
- 1.We recommend aortic root and ascending aortic aneurysms in patients with normally functioning or mildly regurgitant trileaflet aortic valves be treated with valve-sparing procedures whenever feasible (Strong Recommendation, Medium-Quality Evidence).
- 2.We suggest aortic root and ascending aortic aneurysms in patients with moderate or greater insufficiency with or without bicuspid aortic valves be considered for valve-sparing root replacement with or without cusp repair (Weak Recommendation, Low-Quality Evidence).
- 3.We suggest that, in patients who undergo bicuspid aortic valve repair with moderate aortic root dilatation, valve-sparing root replacement be considered to improve repair durability (Weak Recommendation, Low-Quality Evidence).
Considerations for Aortic Valve Replacement in Young Patients With Aortic Dilatation
- 4.For patients with aortic dilatation who require aortic valve replacement, we recommend using a mechanical or biological prosthesis (Strong Recommendation, Medium-Quality Evidence).
- 5.We recommend that the Ross procedure be considered as an alternative for prosthetic valve replacement in young adults with bicuspid and tricuspid aortic valve stenosis and aortic dilatation (Strong Recommendation, Medium-Quality Evidence).
Perfusion Strategies for Aortic Arch Surgery
Cerebral perfusion strategies
- 6.We recommend right axillary artery cannulation or innominate artery cannulation be considered for complex aortic arch reconstruction or acute type A aortic dissection repair to facilitate ACP (Strong Recommendation, Medium-Quality Evidence).
- 7.We suggest deep hypothermia alone be considered as an isolated brain protection strategy for shorter durations of circulatory arrest (< 30 minutes) (Weak Recommendation, Medium-Quality Evidence).
- 8.We recommend ACP be used when the anticipated duration of circulatory arrest is > 30 minutes to help preserve brain function (Strong Recommendation, Medium-Quality Evidence).
- 9.We suggest lesser degrees of hypothermia may be used for aortic arch procedures when ACP strategies are used (Weak Recommendation, Medium-Quality Evidence).
Extended Distal Repair for Type A Aortic Dissections
Rationale for extended distal repair
Techniques of extended distal aortic reconstruction for type A dissection
- (1)Total arch replacement with orthotopic arch vessel reimplantation and antegrade stent graft placed in the descending aorta at time of circulatory arrest.71-74
- (2)Hemiarch replacement with antegrade stent graft placed in the descending aorta at time of circulatory arrest.75-79 The arch vessels and a short segment of the native arch are left in situ.
- (3)For arch debranching extra-anatomic proximal rerouting of arch vessels with ascending aortic replacement and stent graft deployment off pump with intraoperative fluoroscopy is used to determine landing zones.80-84 In this approach the stent graft may be deployed antegrade or retrograde.
- 10.We recommend replacement of the ascending aorta during systemic circulatory arrest with an open distal anastomosis to be used routinely for repair of acute type A dissections (Strong Recommendation, Low-Quality Evidence).
- 11.We recommend that an extended distal arch repair technique be considered for patients who present with acute type A dissection and one of the following:
- i.Primary intimal entry tear in the arch or descending aorta
- ii.Significant aneurysmal disease of the arch
- (Strong Recommendation, Low-Quality Evidence).
- 12.We suggest that it is reasonable to consider an extended distal arch repair technique for patients who present with acute type A dissection and one of the following:
- i.Concomitant descending thoracic aortic aneurysm (DTAA)
- ii.Distal malperfusion
- iii.Young patients
- iv.Patients with known connective tissue disorders
- (Weak Recommendation, Low-Quality Evidence).
Contemporary Total Arch and Hybrid Arch Repair for Aneurysmal Arch Disease
- 13.We suggest that hybrid arch repair be considered in patients deemed too high-risk for conventional open repair who meet specific anatomic criteria (Weak Recommendation, Low-Quality Evidence).
- 14.We suggest that hybrid arch techniques might be considered for single-stage repair in patients with diffuse aneurysms involving the ascending, arch and descending aorta (mega aorta) (Weak Recommendation, Low-Quality Evidence).
Total Endovascular Arch Repair
- 1.Chimney technique: a covered endovascular stent graft placed across the arch with parallel stents deployed in the arch branches.97,98
- 2.In situ fenestration: a covered endovascular stent graft is first placed across the arch and then fenestrations created for perfusion of the branch vessels. This technique has usually been reserved for the left subclavian artery.99
- 3.Custom-made fenestrated or branched endografts.100-102
- 15.We suggest that closed-chest arch reconstructions only be considered for patients at high risk for open or hybrid repair (Weak Recommendation, Low-Quality Evidence).
- 16.We recommend DTAAs with appropriate anatomy and etiology be treated with thoracic endovascular repair (Strong Recommendation, Medium-Quality Evidence).
Type B Aortic Dissection
Acute type B dissection—complicated
Acute type B dissection—uncomplicated
- 17.We recommend that endovascular repair be first-line therapy for complicated type B aortic dissections to reduce mortality and morbidity (Strong Recommendation, Medium-Quality Evidence).
- 18.We recommend that patients with uncomplicated acute type B aortic dissections be managed with hypertension and pain control and radiologic surveillance (Strong Recommendation, Medium-Quality Evidence).
- 19.We suggest that endovascular repair be considered for patients with uncomplicated type B aortic dissections to improve aorta-specific end points (Weak Recommendation, Low-Quality Evidence).
Chronic type B aortic dissection
- 20.We recommend that patients with chronic type B aortic dissections who have indications for repair and have acceptable surgical risk receive open surgical repair with consideration of endovascular or hybrid repairs reserved for patients with high surgical risk (Strong Recommendation, Medium-Quality Evidence).
Options for the Distal Landing Zone
- Supplemental Material
The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.