Aortic endarterectomy: is it still a safe procedure in the twenty-first century?
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INVITED EDITORIAL
Aortic endarterectomy: is it still a safe procedure in the twenty-first century? Bashi Velayudhan 1 Received: 7 August 2020 / Revised: 23 August 2020 / Accepted: 26 August 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
“Porcelain aorta” always poses a challenge to the cardiac surgeon. Technical difficulties while encountering a “porcelain aorta” include the aortic cannulation, aortic cross-clamp, site, and ease of closure of aortotomy. The ways to handle patients with porcelain aorta who need aortic valve replacement (AVR) include: i. Replacement of the ascending aorta with AVR or Bentall’s procedure on deep hypothermic circulatory arrest (DHCA) ii. Find a “safe zone” to perform aortotomy and complete the AVR iii. Transcatheter aortic valve replacement iv. Aortotomy under DHCA or cross clamp followed by endarterectomy of the aorta v. A bypass from the left ventricle to descending thoracic aorta with a valved conduit. It has to be emphasized that there should be minimum handling of the aorta to avoid any embolic phenomenon. The first surgical option of replacing ascending aorta/ Bentall’s is safe and many authors have published excellent results in the literature. The second option is tricky and is possible in relatively lesser grades of “porcelain aorta,” where there is a “safe zone” to perform and close the aortotomy site [1]. In the era of transcatheter aortic valve implantation (TAVI), a bypass from the left ventricle to the descending thoracic aorta is rarely performed. Aortic endarterectomy was the treatment of choice for this subset of patients in the previous century. As techniques and results of Bentall’s procedure and cerebral protection evolved, endarterectomy was discontinued in major centers in the early part of this century. The calcification of the aorta need not * Bashi Velayudhan [email protected] 1
Institute of Cardiac and Aortic Diseases, SRM Institutes for Medical Science (SIMS Hospitals), Chennai 600 026, India
always be restricted to the intima. Many a time, the process of calcification extends into the medial layer of the aorta depending upon the pathology [2]. Performing an endarterectomy in these patients will make the aortic wall thin; leaving only a part of media and adventitia to support the aortic wall. It is like removing a few warriors from the “shield-wall” in battle, making it vulnerable and paving way for the big collapse. There is a strong relation between calcified aorta and hypertension. The weakened aortic wall coupled with hypertension can trigger the “big collapse” in these patients. There is only limited long-term follow-up after endarterectomy, and the risk of aneurysmal degeneration or even rupture is unknown. It can even be speculated that the damaged aortic wall can even initiate a deleterious aortic dissection. There is no study at present to support the surgical technique of endarterectomy, even as a bailout procedure. Furthermore, the incidence of the stroke in these patients is as high as 34% in a report [3]. In an article p
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