Evolving Strategies in Aortic Arch Repair (Podcast)

Operations on the aorta constitute the fastest-growing category of cardiac surgery in the U.S. Today more than 20% of the approximately 6,000 cardiac operations done at Cleveland Clinic involve the aorta. The share of aorta operations at the national level is lower but rising in recent years, reaching 9.5% in the latest data from the Society of Thoracic Surgeons database.

“I think we’re going to continue to see more and more patients with aortic disease undergoing operations,” says cardiothoracic surgeon Eric Roselli, MD, Director of the Aorta Center at Cleveland Clinic.

“It’s a growing treatment area largely because we’re learning so much more about aortic disease and how we can help patients with it,” adds Patrick Vargo, MD, another cardiothoracic surgeon with the Aorta Center. “Aortic disease was largely underappreciated or underdiagnosed for a long time, in part due to insufficient awareness because it’s often an asymptomatic disease until it’s an emergency. But another reason treatment and awareness have grown is that the technologies for imaging and monitoring it have improved so much, including genetics and tools for family screening.”

“We’re identifying disease sooner, which allows us to provide planned, elective operations more often, which is of course safer,” Dr. Roselli notes. “But we’re also getting far better at treating it.”

Those improvements in the surgical treatment of aortic disease —particularly involving the aortic arch — are the focus of a recent episode of Cleveland Clinic’s Cardiac Consult podcast. Drs. Roselli and Vargo explore the current and future states of aortic arch repair, addressing the following:

• The specific challenges of aortic arch surgery
• The aortic conditions that most commonly require repair
• Staged and less-invasive treatment approaches
• Emerging branched stent devices and investigational technologies
• Strategies for protecting the brain during arch surgery
• The imperative for continuing postoperative surveillance and multidisciplinary care coordination

Click the podcast player above to listen to the 24-minute episode now or read on for an edited excerpt. Check out more Cardiac Consult episodes at clevelandclinic.org/cardiacconsultpodcast or wherever you get your podcasts.

Excerpt from the podcast

Patrick Vargo, MD: Many times, a life-saving emergency operation for an acute dissection involves just the front part of the aorta because that’s where the tear starts, and that will stabilize and save a patient. But the tear often propagates or continues along the length of the aorta as the heart is beating when the tear happens. Of course, the aorta is a very long blood vessel that goes through the length of the chest and the abdomen. You can’t fix all those areas of the aorta these in one operation, nor should you. It’s too extensive of an operation.

Many of the ways we’ve evolved to treat the aorta over the years have been with staged procedures. Very often we’re seeing arch dissections come back that may have been there for some years, but they've gotten bigger over time, and they are turning into an aneurysm. Those are some of the patients we’re seeing, right?

Eric Roselli, MD: For sure. At some centers like ours, during the emergency, a patient might get their arch replaced, but most places don't necessarily do that. We see chronic dissections. After a patient has survived an acute dissection, they’re still at risk for developing late problems like an aneurysm. Or we see degenerative aneurysms that people may have that involve an area where it’s complex to repair and take care of the heart and the brain at the same time. So patients want to be in an aorta center that’s very facile with cases like that. We do probably 150 arch replacements a year and our outcomes are outstanding. But tell me, Patrick, when you are making a staged plan for a patient with chronic dissection, how do you determine exactly when to intervene?

Dr. Vargo: The two big factors we usually look at in a chronic situation where we're monitoring or watching an aorta are related to size. First, how big is the overall size of it? As it gets bigger, there is an increased risk for it rupturing or having internal bleeding. Then, similarly, we also want to see how it's changing over time. The first time a patient comes to see us, we just have a snapshot in time: Is the aorta dilated and, if so, how much? But as we follow and surveil patients and keep an eye on the aorta, we also see a change sometimes. If it’s changing quickly, even if it's not at a very large diameter, we may intervene because of that rapid change.

Dr. Roselli: Yes, and it's impossible to predict too. In some people, the aorta will grow quickly and they'll have an emergency and will need another intervention within the same year. In other people you can watch the aorta for a decade or more. But once a patient has aortic disease, it's a chronic condition that needs to be managed and monitored by a team that understands the nuances about how to take care of it, when to take care of it and how to take care of any of the segments in the best way.