Surgical management
depends on the type and location of the TAA. Repair of proximal arch aneurysms requires cardiopulmonary bypass and circulatory arrest. Preclotted woven polyethylene terephthalate (Dacron) is the graft of choice. The ascending and transverse arches are repaired through a median sternotomy incision. The descending and thoracoabdominal aortas are approached through a left posterolateral thoracotomy incision. Intraoperative management of patients undergoing thoracotomy is facilitated by selective ventilation of the right lung using a double-lumen endobronchial tube. Cerebrospinal fluid drainage during and after surgery for descending and thoracoabdominal aneurysms can lower the incidence of postoperative paraplegia.
Ascending aortic arch aneurysms
- Indications for surgical repair include symptomatic or rapidly expanding aneurysms, aneurysms greater than 7 cm in diameter, ascending aortic dissections, mycotic aneurysms, and asymptomatic aneurysms greater than 5.5 cm in diameter in patients with Marfan syndrome (Coron Artery Dis 2002;13:85).
- Operative management. An aneurysm arising distal to the coronary ostia is replaced with an interposition graft. A proximal aneurysm resulting in aortic valve incompetency is replaced with a composite valved conduit (Bentall procedure) or a supracoronary graft with separate aortic valve replacement. Ascending arch aneurysms due to Marfan syndrome or cystic medial necrosis are repaired with aortic valve replacement owing to the high incidence of valvular incompetence associated with aneurysmal dilation of the native aortic root. When a composite graft is used, the coronary arteries are anastomosed directly to the conduit.