Concomitant Procedures
Any condition can coexist in patients undergoing aortic surgery, however the majority of conditions are usually vascular in nature.
Simultaneous coronary disease is not unusual. The only catch is whether to use the LIMA. In patients with aortic arch or descending aortic problems the answer is probably no. All patients even with normal root, ascending and arch of aorta who are about to undergo distal aortic surgery should be evaluated for underlying coronary disease pre procedure, and this should be corrected if appropriate.
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Full article
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Highlighted changes
ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery
Mitral regurgitation either primary, secondary to ventricular dysfunction or aortic valve disease is common. In the setting of severe aortic regurgitation and ventricular volume overload, annular dilation is common and often annuloplasty is all that is required. Otherwise the mitral valve is treated on its own merits as usual.
Guidelines for the Management of Patients With Valvular Heart Disease
Concomitant carotid disease is common. The exact site, severity, and symptoms must be carefully evaluated, in the context of the proposed aortic procedure. Asymptomatic patients rarely require surgical intervention, as per current guidelines. The role of simultaneous carotid and cardiac surgery is still hotly debated. In the setting of ostial stenosis of the common carotid arteries or innominate artery disease in patients undergoing aortic arch surgery the anatomical stenosis are resected or bypassed depending on the exact aortic procedure. The most common site of carotid artery disease is at the carotid bulb. This can be dealt with either pre or post aortic procedure via a separate neck incision in virgin anatomical territory, either under LA or GA.
Goiters are common in elderly patients undergoing aortic surgery. If retrosternal they should probably be resected at the same time as the aortic surgery, since post median sternotomy adhesions will make subsequent thyroidectomy difficult. Sometimes the thyroid if enlarged has to be removed anyway because it gets in the way of anastomoses to the innominate artery or the common carotid arteries.
Future procedures may necessitate additional surgical maneuvers.
Future surgery may mean that tissues valves are utilised, sometimes even in the mitral position, when further extensive surgery is required especially in elderly patients.
Stenting of the arch and proximal descending aorta may require the insertion of an extra anatomical graft from ascending aorta to innominate and carotid arteries. The origins of the native vessels should be tied off to prevent endoleaks.
Insertion of an elephant trunk may help in the second stage of repairing a thoracoabdominal aneurysm after a previous arch repair.