Aortic arch debranching: CT or Vascular?

[hellooonurse]

Hi friends, I was watching this Tedtalk (unfortunately not allowed to post links yet) by a Vascular surgeon who talked about aortic arch debranching which seems stupid wicked cool, but I'm curious if vascular surgeons actually get to do that or if that's relegated to the CT surgeons?

Looking at clips of the procedure, it definitely employs a lot of vascular techniques that I'd assume the vascular guys would be the pros of. But it IS the thorax, so in my limited med student knowledge I think that forks it over to CT? Is it possible that both are able to do it (I mean the vascular guys get to do thoracic outlet syndrome) or is it strictly CT territory?

Just curious, and thanks for any insights!

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[DrStephenStrange]

It's not unusual for 2 surgeons to work together in the same OR. A CT surgeon may work in conjunction with a Vascular surgeon to make it happen.

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[LucidSplash]

Where I am doing my vascular fellowship, these patients are primary CT patients but my chair or one of the other senior vascular guys scrubs in as co surgeon. Sometimes they need a TEVAR after and we’ll do that a couple days later if they are doing ok. But we sign off after a couple days and CT does the heavy lifting.

 

[TypeADissection]

Aortic arch debranching is very firmly within the purview of CTS. I also wouldn't use the word "relegated" when it comes to the CTS guys doing arch work. That's a harrowing piece of real estate to work in. At my institution, we aren't a high volume place for open thoraco/arch work and for better or worse, I won't graduate conversant in putting people on left heart bypass by myself as some of my other colleagues who train at higher volume institutions will. In my very biased opinion though, I do think the aortic arch is the most interesting area of the body. Cheers.

 

[Jolie South]

Hi friends, I was watching this Tedtalk (unfortunately not allowed to post links yet) by a Vascular surgeon who talked about aortic arch debranching which seems stupid wicked cool, but I'm curious if vascular surgeons actually get to do that or if that's relegated to the CT surgeons?

Looking at clips of the procedure, it definitely employs a lot of vascular techniques that I'd assume the vascular guys would be the pros of. But it IS the thorax, so in my limited med student knowledge I think that forks it over to CT? Is it possible that both are able to do it (I mean the vascular guys get to do thoracic outlet syndrome) or is it strictly CT territory?

Just curious, and thanks for any insights!

In my institution, those would be joint cases. I think it’s better that way. CTS knows how to go on cardiopulmonary bypass and open and close the chest day in and day out. They manage these patients post op and we see them and place endografts if necessary.

In any case, unless at a very specialized center this is not that common.

 

[hellooonurse]

Ah thank you guys for the responses! Makes sense CT is primary but that it might be a joint procedure. I am currently fascinated by vascular procedures so I've been trying to explore the more!

I also wouldn't use the word "relegated" when it comes to the CTS guys doing arch work. That's a harrowing piece of real estate to work in.

My apologies, I just looked up the definition of relegated: "consign or dismiss to an inferior rank or position."
Totally did not mean to infer that CT is inferior to vascular...I honestly thought relegated was synonymous with saying it was "reserved for" or "strictly designated to".

 

[deleted745951]

Sorry for sidetracking this thread. I'm just a clerk who's on a surprisingly quiet night in the birth unit.

Given the advancement of Thoracic arch endografts and Aortic centers of excellence, do you believe there would be a paradigm shift with Vascular getting a bigger chunk of the Aortic arch pie?

PS: OP, the only Aortic arch debranching I've seen in my institution, involved a CT/VS approach, with the residents doing the sternotomy and exposure, Both attendings were comfortable with the debranching and the Vascular surgeon doing the TEVAR.

 

[filter07]

The only debranching we did with purely vascular surgery was a brachiocephalic bypass with a side biting clamp on the ascending aorta. This didn't require CPB.

I'm perfectly happy letting CT do all the arch debranchings. I might be interested in doing aortic arch stent grafts but it would really depend on how collegially I can work with the CT surgeons. Needless to say, if they don't back me up, I'm not doing them.

 

[dienekes88]

Either cardiac or combined cardiac and vascular.

I've seen it done a couple different ways, and I don't think it's that great an operation. Even though Zone 0 deployment should reduce the risk of Type 1 endoleak compared to Zone 1 or maybe even zone 2 deployment, you have to think that even with standard TEVAR, which should have fairly reasonable proximal and distal landing zones, there's a distinct risk of reintervention due to disease progression, endoleak, etc. and aortic death (look at the MOTHER registry and the follow up to VALOR).

Aortic arch debranching is very firmly within the purview of CTS. I also wouldn't use the word "relegated" when it comes to the CTS guys doing arch work. That's a harrowing piece of real estate to work in. At my institution, we aren't a high volume place for open thoraco/arch work and for better or worse, I won't graduate conversant in putting people on left heart bypass by myself as some of my other colleagues who train at higher volume institutions will. In my very biased opinion though, I do think the aortic arch is the most interesting area of the body. Cheers.

I agree. The arch is pretty cool.

Skip left heart bypass and do partial cardiopulmonary bypass. It'll give you the option to circ arrest. Definitely helpful for giant aneurysms, connective tissue disease, and difficult proximal necks (e.g. calcified aorta).

Sorry for sidetracking this thread. I'm just a clerk who's on a surprisingly quiet night in the birth unit.

Given the advancement of Thoracic arch endografts and Aortic centers of excellence, do you believe there would be a paradigm shift with Vascular getting a bigger chunk of the Aortic arch pie?

PS: OP, the only Aortic arch debranching I've seen in my institution, involved a CT/VS approach, with the residents doing the sternotomy and exposure, Both attendings were comfortable with the debranching and the Vascular surgeon doing the TEVAR.

Folks will do whatever they think they can. I spoke with a vascular surgeon from Germany who primarily does endovascular repair of the arch and thoracoabdominal aorta.

 

[impreza]

Interesting discussion! Here in our center in Asia, our vascular surgeons routinely do revascularization (primarily hybrid debranching with subclavian-carotid bypass) for elective zone 2 TEVAR without CT being involved. In addition, the CT guys simply lack the endovascular training to perform TEVAR, so most descending thoracic aortic (along with zone 2 arch, I guess) go to vascular.
On the other hand, all ascending aortic and zone 0 arch pathologies would absolutely go to CT.
I'm not sure for anything in between, but I'd guess it's in CT's domain.

 

[LucidSplash]

Interesting discussion! Here in our center in Asia, our vascular surgeons routinely do revascularization (primarily hybrid debranching with subclavian-carotid bypass) for elective zone 2 TEVAR without CT being involved. In addition, the CT guys simply lack the endovascular training to perform TEVAR, so most descending thoracic aortic (along with zone 2 arch, I guess) go to vascular.
On the other hand, all ascending aortic and zone 0 arch pathologies would absolutely go to CT.
I'm not sure for anything in between, but I'd guess it's in CT's domain.

This is basically the same as in the US

 

[AsianPersuasion]

Sorry to hijack, but is there a reason why we don't have a vascular sub-forum?

 

[LucidSplash]

Sorry to hijack, but is there a reason why we don't have a vascular sub-forum?

Probably because except for recently, there hasn't been enough vascular topics to really need a subforum.

I think there was a discussion in some thread awhile back and in general no one felt it was intrusive to the main forum and the vascular folks didn’t feel like it was necessary for our own uses.