Boston Scientific Corporation · NYSE:BSX
Boston Scientific — Technical Presentation (March 2006)
35 slides from Boston Scientific's technical presentation, March 2006
Slide 1: Operative Techniques and Neurologic Protection during Surgery of the Aortic Arch
OPERATIVE TECHNIQUES and NEUROLOGIC PROTECTION during Surgery of the Aortic Arch David Spielvogel, M.D. Division of Cardiothoracic Surgery New York Medical College
Slide 2: Aortic Arch Surgery: Cerebral Protection
Aortic Arch Surgery Cerebral Protection ¾Preservation of neuronal viability during interruption of cerebral perfusion ¾Prevention of cerebral emboli Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 3: Aortic Arch Surgery: Surgical Repair
Aortic Arch Surgery Surgical Repair ¾Integral part of neurological protection strategy ¾Simplicity ¾Flexibility Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 4: Methods of Cerebral Protection
Methods Methods of of Cerebral Cerebral Protection Protection HYPOTHERMIA z Selective Cerebral Perfusion z DeBakey, Cooley 1957, Frist 1986, Matsuda, Kawashima 1989, Bachet “Cerebroplegia”1991, Kazui 1992 z Deep Hypothermic Circulatory Arrest z Griepp 1975 z Retrograde Cerebral Perfusion z Ueda 1990
Slide 5: Simple Arch Replacement
SIMPLE ARCH REPLACEMENT Griepp, et. al. JTCVS, 1975 Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 6: Cognitive Function and Temporary Neurological Dysfunction
Cognitive Function and Temporary Neurological Dysfunction Temporary Dysfunction Duration z Grade 1 simple confusion short z Grade 2 confusion + lethargy short z Grade 3 confusion + agitation short z Grade 4 overt psychosis long z Grade 5 psychosis, parkinsonism long Ergin, et al, 1991 Questions abou
Slide 7: What is the Limit of Safe HCA?
What is the LIMIT of “SAFE” HCA? Actual Q10 directly calculated in 37 Adult patients during DHCA 120 45 Duration of HCA % CMRO2 40 Min 100 35 80 30 25 % CMRO2 60 20 SAFE HCA 40 15 10 20 5 0 0 37 30 25 20 15 10 Temperature °C Questions about this procedure? Click here to have your questions answered
Slide 8: Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 9: Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 10: Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Image Property of David Spielvogel, M.D. Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 11: Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Image Property of David Spielvogel, M.D. Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 12: Trifurcated Graft Surgical Strategy
Trifurcated Graft Surgical Strategy • Axillary artery cannulation • DHCA at mean esophageal temperature of 12.8 °C • Sequential anastomosis of the brachiocephalic vessels to the graft • Repeated aspiration • SCP (selective cerebral perfusion) at 50 – 60 mmHg with flows approx. 10cc/kg/min • Elephant
Slide 13: Axillary Artery Cannulation
Axillary Artery Cannulation Image Property of David Spielvogel, M.D. Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 14: Prevention of embolization
• Prevention of embolization – “ No touch “ technique of dissection prior to and during cooling – Exclusion of the highly diseased aortic arch lumen and origins of the brachiocephalic vessels by branch grafting directly – Selective cerebral perfusion during remaining arch reconstruction (SCP) Questi
Slide 15: Illustrations from Operative Techniques in Thoracic and Cardiovascular Surgery
The following illustrations are taken from Operative Techniques in Thoracic and Cardiovascular Surgery, Volume 10, Issue 1, Spring 2005 Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 16: Extensive thoracic aortic disease
Extensive thoracic aortic disease Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 17: Arterial perfusion via direct cannulation of right axillary artery
Arterial perfusion via direct cannulation of right axillary a. Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 18: Direct cannulation
Direct cannulation Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 19: Reconstructed aortic root
Reconstructed aortic root Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 20: Hemashield Gold Branch Woven Vascular Branch Graft
Hemashield Gold™ 3 Branch Woven Vascular Branch Graft Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 21: Left subclavian anastomosis performed first
Left subclavian anastomosis performed 1st (of 3 brachiocephalic branches) Deep hypothermal circulatory arrest Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 22: Selective cerebral perfusion
Selective cerebral perfusion Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 23: Brachiocephalic vessels oversewn; elephant trunk created
Brachiocephalic vessels oversewn Graft inverted into itself and sewn with felt strip to cut edge of aorta to create “elephant trunk” Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 24: Elephant trunk and Bentall graft trimmed for double beveled anastomosis
“Elephant trunk” and Bentall graft trimmed for “double beveled” anastomosis Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 25: Aortic arch closed with double beveled anastomosis
Aortic arch closed with completion of “double beveled” anastomosis Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 26: Selective cephalic perfusion is not interrupted
Selective cephalic perfusion is not interrupted Trifurcated graft sewn to ascending aortic graft Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 27: Aortic replacement with trifurcated graft attached
Aortic replacement with trifurcated graft attached Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 28: Possible locations for attachment of coronary bypass grafts
Possible locations for attachment of coronary bypass grafts Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 29: Preoperative left subclavian to left common carotid bypass
Preoperative left subclavian to left common carotid bypass Trifurcated graft reduced to bifurcated graft Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 30: In summary
In summary Spielvogel, et al Ann Thorac Surg 2002 Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 31: Ascending Aorta Elephant Trunk in Re-operative Arch Repair
Ascending Aorta Elephant Trunk in Re-operative Arch Repair Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 32: Variations in the position of the Elephant Trunk
Variations in the position of the Elephant Trunk (a) 57 cases (b) 28 cases (c) 6 cases (d) 13 cases Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 33: Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Questions about this procedure? Click here to have your questions answered by Dr. Spielvogel.
Slide 34: Aneurysm Etiologies
Aneurysm Etiologies n (%) Atherosclerosis 41 (37.6%) Chronic dissection 35 (32.1%) Degenerative 22 (20.2%) Ruptured atherosclerotic 5 (4.6%) ulcer Marfan’s aneurysm (non- 2 (1.8%) dissected) Trauma 2 (1.8%) Inflammatory aneurysm 1 (0.9%) False aneurysm 1 (0.9%) Questions about this procedure? Click
Slide 35: Trifurcated Graft Surgical Cerebral Protection (SCP)
Trifurcated Graft Surgical Cerebral Protection (SCP) • Provides general and neurological outcomes comparable to other contemporary strategies. • Minimizes emboli by avoiding instrumentation of the often-diseased proximal brachiocephalic vessels and aortic arch. • Gives flexibility in reconstruction
Boston Scientific — Technical Presentation (March 2006) on 6ix