For Physicians
LEADING EDGE THERAPIES
The Massachusetts General Hospital Thoracic Aortic Center cares for patients with acute and chronic aortic dissections, thoracic and thoracoabdominal aortic aneurysms, Marfan syndrome, coarctation of the aorta, and other thoracic aortic conditions. Our initial medical evaluation of a patient, which includes a general cardiac assessment, determines whether or not intervention is necessary and, if so, what procedure is most appropriate for that patient’s specific condition. In addition to standard therapies, we offer a number of innovative strategies for managing thoracic aortic diseases, including minimally invasive stent-grafts for selected descending thoracic aortic aneurysms, stent-grafting of selected type B dissections, aortic valve preserving operations for ascending aortic aneurysms, and repair of extensive thoracoabdominal aneurysms. Surgical repair of thoracic aortic aneurysms is usually carried out when the aneurysm is large enough in size to carry a significant risk of rupture or cause symptoms. Aneurysms of smaller size are usually managed medically and with periodic imaging.
Thoracic Aortic Center members have reported the largest experience with stent graft repair of thoracic aortic pathology in New England. Stent graft repair for certain cases spanning the spectrum of thoracic aneurysm pathology is now a reality, and compares favorably with conventional surgery in terms of morbidity and mortality. A recently published pivotal trial demonstrated a statistically significant reduction in both operative mortality and spinal cord ischemic complications for stent grafting as compared to open surgery. The Thoracic Aortic Center is also the major referral center for the treatment of thoracoabdominal aneurysms (TAA), in the Northeast. A unique technique for spinal cord protection (epidural cooling) was developed at Massachusetts General Hospital and has been applied since 1993. This method has significantly reduced the risk of spinal cord ischemic complications with TAA resection.
For patients with conditions affecting the ascending and arch portions of the aorta, we offer individualized treatment strategies including innovative procedures. A Dacron graft is used for repair of the aortic aneurysm. For patients with aortic root aneurysms and aortic valve insufficiency, we perform valve preserving aneurysm repairs if the aortic valve leaflets are intrinsically normal. The aortic valve is reimplanted into the graft used to repair the aneurysm. These patients can avoid the use of anticoagulants, and the durability of these repairs appears promising.
For patients who have aortic valve involvement with calcification, perforation, or prolapse of the leaflets in addition to an aortic root aneurysm, we can repair the situation with a variety of valved conduits. Manufactured mechanical valve-graft conduits are implanted in some patients in order to maximize valve durability, and anticoagulation is needed. We custom make tissue valve conduits during surgery for selected patients, especially those over the age of 65 years. Anticoagulants are not necessary with these repairs. Our current techniques result in a dramatic reduction of the need for blood transfusion during operations to implant the valve conduits.
Repair of aneurysms involving the aortic arch requires hypothermic circulatory arrest during implantation of the graft. We have extensive experience with these techniques with excellent results. Either retrograde or antegrade cerebral perfusion techniques are used to provide protection for the brain, and the choice depends on the complexity of the repair and the anticipated time required. The entire arch may be replaced with branch grafts from the main aortic graft extending to each of the three arteries arising from the aortic arch. Alternatively, a partial arch replacement may be performed if the area in which the arch branches arise is not involved with the aneurysm.
Lastly, for patients with coarctation of the aorta, the Center offers direct stenting of the involved aortic segment as an effective but minimally-invasive alternative to surgical repair.
Those who have had thoracic aortic aneurysms or aortic dissection are at increased risk for the development of additional thoracic aortic aneurysms in the future. Recognizing this long-term risk, the Center specialists recommend regular follow-up visits and periodic surveillance with imaging studies improve the long-term prognosis of patients with aortic disease. Optimal control of hypertension is emphasized and patients are encouraged to learn to monitor their own blood pressure to be sure that it remains in the target range between visits.
Minimally invasive procedures include:
- Stent graft insertion for selected descending thoracic aortic aneurysms and pseudoaneurysms, as well as for selected type B aortic dissections and traumatic aortic tears
- “Hybrid” (i.e. combining open and endovascular procedures) for thoracic and thoracoabdominal aneurysms.
- Endovascular management of aortic branch compromise secondary to aortic dissection
Stent Graft/Minimally Invasive Endovascular Surgery
We have the largest experience in New England with stent graft repair of aortic pathology. Stent graft repair for certain cases spanning the spectrum of thoracic aneurysm pathology is now a reality and compares favorably with conventional surgery in terms of morbidity and mortality. Our preliminary experience has indicated stent-graft repair is both safe and effective and avoids the major thoracotomy procedure typically required to repair thoracic aneurysms. Application of stent-graft technology to other lesions, such as acute distal dissections, penetrating aortic ulcers, and traumatic aortic tears, will increase dramatically as ongoing study protocols are completed. We have a fully equipped, state-of-the-art fixed imaging endovascular operating room suite ideally suited for the spectrum of conventional and endovascular surgery.
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Open surgeries include:
Thoracoabdominal Aneurysm Repair
We are a major referral center in the Northeast for the treatment of thoracoabdominal aneurysms. In addition to requiring a complex and extensive surgical repair, correction of aneurysms that involve the thoracoabdominal segment are potentially complicated by spinal cord ischemia. We have developed a means to apply regional hypothermic protection directly to the spinal cord. The adjunctive use of epidural cooling has significantly decreased both the incidence and severity of spinal cord ischemic complications after extensive thoracic aortic resection. A dedicated vascular anesthesia service is an integral component of our approach. With the advent of commercially available thoracic aortic stent grafts, newer strategies with “hybrid” procedures, combining both open and endovascular surgical components, have enabled our surgeons to offer TAA repair to high risk patients unsuitable for conventional surgery.
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Repair of Acute Type A Aortic Dissection
Patients with acute aortic dissection that involves the ascending thoracic aorta require urgent surgery to replace the ascending aorta with a graft. Even when dissections cause aortic insufficiency, we are able to leave the aortic valve and root intact in most cases by repairing the root and re-suspending the valve.
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Aortic Valve-Preserving Ascending Aneurysm Repair
Whenever possible, we do not replace the aortic valve and instead perform an aortic valve-preserving aneurysm repair that has a promising durability. This type of procedure is for patients with aortic root aneurysms and aortic insufficiency but who have aortic valve leaflets that are intrinsically normal. We re-implant the aortic valve and the coronary arteries into the graft used to repair the aneurysm. Patients who have this procedure can avoid the long-term anticoagulation necessitated by some prosthetic valves. We have the most experience with aortic valve-preserving aneurysm repair of any hospital in New England.
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Composite Aortic Root Replacement
When the surgical repair of the aortic root also requires a valve replacement, the patient undergoes a composite aortic root replacement, or valved-conduit, which is a safe, effective and durable operation. By connecting the coronary arteries directly to the Dacron ascending aortic graft, we are able to eliminate late pseudoaneurysm formation at the suture lines, which is a substantial improvement over other surgical techniques. We use both mechanical and tissue valves in these operations. For patients who cannot take anticoagulants or are past the age of 65, a tissue valve allows freedom from life-long anticoagulant medication.
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Aortic Arch Surgery
Aortic arch surgery is technically challenging. We perform more aortic arch repair and replacement surgery than any other center in New England. We may replace the entire arch with branched grafts or perform a partial arch replacement, depending on the extent of the aneurysm. For safety and cerebral protection, we use hypothermic circulatory arrest, supplemented by either retrograde or antegrade cerebral perfusion, which are advanced support techniques. We have found that by using these techniques, patients have a low risk of mortality and stroke.
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Thoracic Aortic Center Contact
Information
 617-724-4747
Massachusetts General Hospital Thoracic Aortic Center
55 Fruit Street, YAW-5800
Boston, MA 02114
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