Aortic arch and descending aorta - surgical criteria?

[tjay]

1) What's the surgical criteria for aortic arch and descending aorta?
- 5.5cm as per newer 2014 guidelines (and 5.0 prior) seems to be the criteria for aortic root and ascending aorta, but it's not clear what arch and descending surgical thresholds are.

2) More importantly, what were your arch and descending dimensions before/when you had an AVR (or root/ascending aorta repair, but not involving arch/descending repair), and what are they now years later?
- I guess what I'm trying to confirm is that while root/ascending aneurysm can continue to develop even after AVR in many cases, arch and descending aneurysms do not seem develop as much afterwards.

3) Is it safe to assume that while aneurysms at root and ascending aorta are very common in BAV, arch and descending aortic aneurysms are relatively much less common, especially after AVR and/or root/ascending repair??
- Basically assessing if someone gets a mechanical AVR along with root and ascending aorta replacement, his/her chances to have a second surgery is fairly slim, correct? There are no guarantee but what else is there to replace if these 3 things hold, probabilistically speaking??

thanks for your responses.

 

[Agian]

I asked the same questions. The aortic valve has the same embryological origin as the ascending aorta. The rest of the aorta is 'normal'. An aneurysm down-stream would be a different disease process. Having said this, BAV is sometimes associated with an aortic coarctation (narrowing). This causes a high BP in the upper part of the body, and a lower BP from the chest down. A lifetime of high pressures in the upper body can contribute to aneurysms, in the brain etc. Without coarctation, your risks of aneurysms elsewhere would be the same as someone without BAV, once corrected. Having said this, an aneurysm can spread, if left untreated. So an out of control ascending aortic aneurysm can make its way up to the arch. This is how I understood the information I was given.

 

[cldlhd]

Mine appears to be making it's way to the arch. I have a 4.8 root and a 4.7 ascending. The beginning of my arch is slightly large . I asked the surgeon if this is because it's connected to the aneurysm nd being stretched by it and he says he believes thats the case.

 

[tjay]

hi cldlhd,
Could you share what the dimension of the beginning of your arch is, and if surgeon is even entertaining touching that during the surgery? Is it in 3s or 4s? At what point it actually becomes a concern, you know?

 

[pellicle]

Hi

Mine appears to be making it's way to the arch. ...I asked the surgeon if this is because it's connected to the aneurysm nd being stretched by it and he says he believes thats the case.

that's interesting and concerning. I guess that he's attempting to see where it stabilizes so that he can "get it all" ; rather than have it appear further down later on.

Not that I know **** about vascular surgery, but to me it would seem prudent to take out earlier and while in there add some reinforcing of the other areas, because the arch is a complex bit of stuff to work on replacing.

certainly its a question that would be on my lips when I visited.

 

[cldlhd]

I believe its in the 3's and he says he'll get it all while he's in there and his nurse claimed he can tell what tissue is likely to become aneurysmal in the future. I agree with the idea of not waiting too long and thats why I'm planning on getting my operation before the end of the year. I believe he's going to replace some of the bottom of the arch along with the ascending. I thought the same as in he's waiting to see where it'll stabilize but he seemed to think it's most likely being stretched just because its one continuous run and connected to the ascending aneurysm and once he weaves his magic it'll be a "definitive solution " and my odds of future aneurysm will be very low.

 

[pellicle]

Hi

again, not that I know about artery walls, but with other materials I know that if a strech starts it may go on unchecked as it progresses along a pipe / hose.

I believe its in the 3's and he says he'll get it all while he's in there and his nurse claimed he can tell what tissue is likely to become aneurysmal in the future.

so just as I'd cut out a section of streching hose (usually fixing it permanently) I'd also ask about using carbon fiber matting to reinforce around the arch ...

again, not that I actually know ... its just a question I'd ask.

 

[tjay]

hi cldlhd,
thanks for your feedback.. Timing for aortic surgery is very personal especially when both the aorta and valve are below the surgical thresholds, but you could probably also use the same insight from numerous others on this forum who've already gone thru root/ascending surgeries. It's a question to them:

While there have been extensive discussions on the root and ascending, nothing much on arch and descending. So can we confirm the hypothesis that primary problem areas for BAVers is root/ascending (occasionally coarctation as Again pointed out) and it doesn't spread to arch/descending easily, before or after the aortic surgery.

What were your arch/descending dimensions before the surgery and years later? Do you even image (e.g. CT, MRI) arch/descending on periodic basis and does your cardiologists even care to monitor them during your routine exams??

It would be nice to rule out at least a few problems from the likelihood.

PS: My aorta dimensions from CT scan are: (Age 44yrs) root 4.8cm (4.5cm in echo), ascending 4.2cm, arch 2.7cm, descending 2.6cm. 12 years back (Age =32) from CT were 4.5cm, 3.8cm, 2cm, 2cm respectively.
I came across another literature that even normal aorta grows in size somewhat, including into the age of 30s, 40s and 50s (See Figure 2 (A), also Table 1):
Age-Related Changes in Aortic Arch Geometry - http://content.onlinejacc.org/article.aspx?articleid=1146777

Would like to paste the chart from the publication here so that you don't have to scan the whole article, but not sure you a picture can be pasted in this text box. Let me know how.

 

[cldlhd]

My surgeon said he believes the arch is genetically similar to the ascending not the descending which isn't what I wanted to hear but he seems confident he can remove all the bad material. He repeatedly used the phrase "definitive solution".

 

[AZ Don]

1) What's the surgical criteria for aortic arch and descending aorta?
- 5.5cm as per newer 2014 guidelines (and 5.0 prior) seems to be the criteria for aortic root and ascending aorta, but it's not clear what arch and descending surgical thresholds are.

I checked the 2014 guidelines (2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease) and there is little mention of the arch and descending aorta. Dilation of the root and ascending aorta is discussed in association with BAV. From memory I believe I've seen it mentioned that the criteria for surgical intervention on the descending aorta is as much as 1cm beyond the criteria for the ascending. This older paper http://www.sciencedirect.com/science/article/pii/S0735109709040753
mentions that it is higher but not sure that it mentions any specific criteria.

2) More importantly, what were your arch and descending dimensions before/when you had an AVR (or root/ascending aorta repair, but not involving arch/descending repair), and what are they now years later?
- I guess what I'm trying to confirm is that while root/ascending aneurysm can continue to develop even after AVR in many cases, arch and descending aneurysms do not seem develop as much afterwards.

No idea. My surgeon showed me the cross sectional view of my aorta, showing how it ballooned out and then narrowed again, to 3cm or so, but we did not discuss my arch or descending aorta.

3) Is it safe to assume that while aneurysms at root and ascending aorta are very common in BAV, arch and descending aortic aneurysms are relatively much less common, especially after AVR and/or root/ascending repair??
- Basically assessing if someone gets a mechanical AVR along with root and ascending aorta replacement, his/her chances to have a second surgery is fairly slim, correct? There are no guarantee but what else is there to replace if these 3 things hold, probabilistically speaking??

That is my understanding - that BAV is primarily associated to aneurysms of the root and ascending aorta. That said, I think there is a lot yet to learn. My Cardiologist told me that we have to assume that my arteries may be less well formed than normal and so I may have some risk for another aneurysm. There is even a study indicating a higher risk of Brain aneurysm in those with BAV, though I found another study that reached the opposite conclusion. I do know there are people that have had multiple aneurysms, but I think it is pretty rare. I don't think having an AVR or an aneurysm repair has any impact on the likelihood of an aneurysm developing in another spot, other than eliminating the risk of the initial aneurysm spreading or dissecting down the aorta.