Aortic pathology | Aortic surgery | Important imaging features | Utility of tomographic imaging |
---|---|---|---|
Aortic valve and aortic root pathology | Composite valve–aortic graft and coronary reimplantation (Bentall's procedure) | ▸ Proximal anastomosis at the aortic annulus, extending to the ascending aorta ▸ Aortic valve replacement can either be mechanical or bioprosthetic ▸ Coronary reimplantation involves excising tissue buttons surrounding the coronary ostia and anastomosing to the prosthetic root | ▸ Assess distal anastomosis ▸ Assess coronary ostia ▸ Assess aortic valve (if echocardiography suboptimal) |
Aortic root pathology, with structurally normal aortic valve | Modified David's procedure (valve sparing aortic root replacement) with coronary reimplantation | ▸ Proximal anastomosis at the aortic annulus, extending to the ascending aorta ▸ Coronary reimplantation involves excising tissue buttons surrounding the coronary ostia and anastomosing to the prosthetic root | ▸ Assess distal anastomosis ▸ Assess coronary ostia ▸ Assess aortic valve (if echocardiography suboptimal) |
Ascending aortic pathology with normal aortic root | Supracoronary ascending aortic grafting | ▸ End-to-end aortic anastomosis from the sinotubular junction, without aortic root replacement | ▸ Assess proximal and distal anastomosis |
Ascending aortic pathology, extending only to proximal arch | Supracoronary ascending aortic and hemi-arch grafting, preserving native arch branch vessels | ▸ Anastomosis of the arch branch vessel origins are via a peninsula of the native arch roof, continuous with the native descending thoracic aorta | ▸ Assess proximal and distal anastomosis |
Ascending aortic, arch and descending aortic pathology | Ascending, arch grafting, elephant trunk (stage I and II surgical completion) with arch vessel debranching OR Ascending, arch grafting, elephant trunk (stage I surgical grafting and stage II endovascular stent graft completion of descending aortic pathology) with arch vessel debranching OR Frozen elephant trunk34 | ▸ Distal end of the aortic arch graft dangles freely within the proximal descending aorta, distal to the distal surgical anastomosis near the aortic isthmus ▸ The dangling end of the elephant trunk graft can be identified by metallic markers on the distal graft end ▸ The dangling end distally prepares for a second stage surgical completion or percutaneous stent-graft implantation in the descending thoracic aorta ▸ Frozen elephant trunk technique combines the conventional proximal aortic replacement and endograft deploying in the descending aorta in one setting ▸ Intercostal arteries are sometimes reimplanted into grafts | ▸ Assess proximal and distal anastomosis ▸ Assess patency of arch branch vessels ▸ Assess for endoleak surrounding the stent (if present) |
Descending aortic pathology only | Surgical grafting OR Endovascular stent grafting | ▸ Left subclavian artery ostium is often covered in endovascular stent grafting; surgical left carotid to left subclavian bypass graft can often be seen | ▸ Assess proximal and distal anastomosis ▸ Assess for endoleak surrounding the stent ▸ Assess patency of left carotid to left subclavian bypass graft |