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Ann Thorac Surg 1999;67:2014-2019
© 1999 The Society of Thoracic Surgeons

Discussion: session 8—aortic dissection

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Dr D. Craig Miller (Stanford, CA)

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
I have one question for Dr Bachet. I have only used gelatin-resorcinol-formol glue a few times, when you and my Spanish and German colleagues have allowed me to smuggle it in, and I probably have not used it correctly. It was not dry enough; it was not warm enough: those technical details. But I was not impressed. On the other hand, I have had the opportunity to reoperate on patients who have had glue used during operations in Europe and in Quebec, and it looked as though there was full-thickness necrosis where the glue had been placed. That was quite disturbing, and also raises the question of false aneurysms. Tell us your experience with late complications of the glue, if any.

	Dr Jean Bachet (Suresnes, France)

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
We have reoperated on a lot of patients. I have no memories of any complications during those reoperations linked to the fact that the patients had the glue. We found a fibrous aorta, as in any redo procedure. In comparison with patients on whom we reoperated, some of whom have had their first procedure in other centers and had Teflon, there is a very big difference. Because Teflon is hell, and I have really no memory of bad complications with the gelatin-resorcinol-formol glue.

	Dr Miller

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
That’s reassuring.

	Dr Aram Smolinsky (Tel Hashomer, Israel)

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
I would like to answer your question. We are fortunate enough to have had the glue, as much as we want, for quite a few years. I have had at least five or six reoperations in patients who had glue before, and I am so unenthusiastic about it that we nearly stopped using the glue--the French glue. On the distal anastomosis in aortic dissection we still use it. This is completely dead tissue, and it really strengthens the suture line. But on late follow-up there is absolutely no strengthening of the suture line anymore. With Teflon felt, with suturing of tissue, the scar becomes stronger with time. With glue, there is, in our experience, no strengthening of the suture line. We had a few patients who had a reoperation, and there was actual dehiscence of the proximal suture line. This has convinced us to use absolutely no glue in the proximal site in aortic dissection. In contrast to Dr David, we do have the glue, and we completely stopped using it in the proximal suture line in aortic root repairs. We have a series of 12 repairs in acute aortic dissection, and we use glue exclusively on the distal part if we need to.

	Dr Miller

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
So glue may not be perfect.

	Dr Smolinsky

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
Apparently not.

	Dr Miller

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
We heard someone say yesterday that the Yacoub or T. David II remodeling procedure should be the procedure of choice in acute aortic dissection, and I shuddered because Dr Yacoub’s results are poor in dissection patients. I noticed in your presentation that only 28% had a remodeling procedure. When should you remodel and when should you not?

	Dr Tirone E. David (Toronto, Canada)

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
In dissection, the reimplantation of the aortic valve is far safer, simpler, faster, and nothing leaks because the whole aortic valve is resuspended inside a Dacron graft.

	Dr Miller

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
You mean then you recommend a Tirone David I, with the entire valve up inside the Dacron tube graft?

	Dr David

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
Yes. And in follow-up there is no difference whatsoever in performance. In the report by Dr Carlos Duran and his associates from Saudi Arabia in which the leaflet banged against the graft and wore off, it is because he is putting it in too small a graft. Intraoperatively you can see the leaflet open and close, and it does not come near the wall. It leaves about a 5 mm or 6 mm gap before it touches the graft wall. So I think the reimplantation technique is the best one for patients who have a dilated or dissected aortic root in this disease.

	Dr Hideo Adachi (Omiya, Japan)

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
I would like to ask Dr John Elefteriades a question. I understand the usefulness of fenestration for the patient with malperfusion. My concern is bleeding. The distal anastomosis site is okay because we fix the aortic wall. However, at the proximal site, we have to use a very thin wall. Are you using some felt to secure the anastomosis, or do you not have a bleeding problem?

	Dr John A. Elefteriades

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
(New Haven, CT): That is a very good question. We have no bleeding problem, even though the upper aorta is only adventitia. It has no media because we have cut out both media and intima. Bleeding is just not a problem. I think there is a lot of strength in the adventitia. And the diameter is small, so the wall tension is lower. It has not been a problem.

	Dr Adachi

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
What size suture material are you using?

	Dr Elefteriades

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
4-0.

	Dr Miller

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
4-0 suture, fine needle. I think you’ve heard that several times in dissection, although Dr Cooley would disagree. He would probably use a large MH needle, but I do not know how he gets away with it in acute dissections.

	Dr David

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
Why should a fenestration below the renal artery protect the gastrointestinal tract? Suppose the patient presents with mesenteric ischemia? Why should we fenestrate below the renal arteries as opposed to the thoracic aorta with a catheter?

	Dr Elefteriades

Top Dr D. Craig Miller... Dr Jean Bachet (Suresnes,... Dr Miller Dr Aram Smolinsky (Tel... Dr Miller Dr Smolinsky Dr Miller Dr Tirone E. David... Dr Miller Dr David Dr Hideo Adachi (Omiya,... Dr John A. Elefteriades Dr Adachi Dr Elefteriades Dr Miller Dr David Dr Elefteriades Dr Miller Dr Roger C. Millar... Dr David Dr Millar Dr David Dr Miller Dr David Dr Millar Dr David Dr Millar Dr Miller Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Edward A. Pascoe... Dr Miller Dr G. Michael Deeb... Dr Miller Dr Pascoe Dr Miller Dr Deeb Mr Stephen Westaby (Oxford,... Dr Miller Dr Elefteriades Dr Miller Dr Steven L. Lansman... Dr Miller Dr Lansman Dr Miller Dr Erik Gundersen (LaCrosse,... Dr David Dr Miller Dr Bachet Dr Miller Dr Bachet Dr Miller Dr Lansman Dr Miller Dr Bachet Dr Miller Dr Antonio Marullo (Cleveland,... Dr Miller Dr Renzo Pessotto (Verona,... Dr Miller Dr Deeb Dr Miller Dr Joseph M. Arcidi... Dr Miller Dr Lansman Dr Miller Dr Adachi Dr Miller Dr Arcidi Dr Miller Dr Lansman Dr Miller Dr Robert A. Dion... Dr David Dr Miller Dr M. Arisan Ergin... Dr David Dr Ergin Dr David Dr Ergin Dr David Dr Miller Dr David Dr Miller Dr Deeb Dr David Dr Miller Dr David Dr Randall B. Griepp... Dr David Dr Griepp Dr David Dr Michele F. Roesler... Dr Miller Dr Lansman Dr Miller Dr Noedir A. G.... Dr Miller Dr Stolf Dr Antonio C. Carvalho... Dr Miller Dr Carvalho Dr Miller

 
We were surprised to find that fenestration works for lesions above the fenestration site. As you point out, Dr David, in the case of leg ischemia, you have at least redirected the blood flow into the true lumen, but our impression is that there must be some value to the fact that with fenestration you have taken the pressure off the false lumen. I think these people who have malperfusion very often have no reentry site, and it may be that you are providing a reentry site and decreasing the size of the false lumen.

	Dr Miller

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You had obstruction from the false lumen, extrinsic compression, obliterating the true lumen of the aorta in the region of the celiac and the superior mesenteric arteries, or what we call true lumen collapse; when the false lumen is decompressed by flap fenestration, the true lumen gets larger.

	Dr Roger C. Millar (Salt Lake City, UT)

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In type A dissections where you have severe aortic insufficiency with dissection down into the sinuses, in what percentage of patients, Dr David, do you use your reconstruction, and how often do you do all three sinuses, or one, or two?

	Dr David

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In all 17 cases that I did personally, if the leaflets are normal, I remove all three sinuses, because, as I mentioned, that is the condition where I reimplanted the aortic valve. You take all three sinuses out, use 10 or 12 sutures in the inflow of the aortic valve, just below the leaflets, and that is our annuloplasty. And then resuspend the aortic valve into a conduit, like a homograft. So really you remove all the dissected tissues and leave no place for any leakage.

	Dr Millar

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If the aorta is not dissected around the left coronary artery, just the right and non-coronary sinuses, would you just resect those two?

	Dr David

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I do not recall having done any cases like that, to be quite honest. All the dissected ones are outside the annulus in the aortic root. It is very seldom that you have a normal aortic root in dissections that start in the ascending aorta. Almost invariably if patients have a tear in the ascending aorta, they have a dilated aortic root. I would say more than half of them do. So if the left sinus is not dissected but is dilated, I think it is better to resect, to be a bit more radical.

	Dr Miller

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Let me ask that question another way. Do you still find use for the old-fashioned saving the aortic valve and sinuses? Have you done that in the past 7 years?