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Mehmet Ates, ICVTS on-line discussion A, Interactive CardioVascular and Thoracic Surgery, Volume 5, Issue 4, August 2006, Pages 458–459, https://doi.org/10.1510/icvts.2005.126318A
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eComment: I would like to make a few comments concerning the case report ‘Open stent grafting: aborted procedure in a patient with mega aorta syndrome’ by Bashar et al. [1].
According to postoperative magnetic resonance imaging, second stage operation should be performed because this view showed a Crawford type II thoracoabdominal aneurysm. I would like to ask the authors what is mega aorta, an aortic diameter more than 10 cm or not? When I was working next to Dr. Coselli in Houston, one time he performed Crawford type II thoracoabdominal aneurysm which was 18 cm and he said: I performed a 24 cm thoracoabdominal aneurysm, when we can say mega aorta, we have to determine it. In my opinion, if aortic diameter is more than 10 cm, we can say mega aorta.
Patients with mega aorta syndrome are treated with replacement of the entire aorta by conventional surgical procedures in stages. Staged surgical strategy is highly invasive but it is not a hazardous procedure. Therefore, many aortic surgeons perform two stage operations with acceptable mortality and morbidity ratio.
I think also this patient needs a second operation because, according to figure 5, thoracoabdominal aneurysm is still continuing and its edge is nonuniform. He needs to have this operation performed within 2 years. If we run across all aortic diseases which have ascending, arcus and descending aneurysm, we have to determine what the priority is. Usually, the first stage ascending and arcus aorta have been changed and elephant trunk procedure performed. In this situation, deep hypothermic circulatory arrest time can be 40–60 minutes safely. In second stage, patient is accepted as a Crawford type II thoracoabdominal aneurysm and performed on. If thoracoabdominal repair has to be performed as a first stage, the most important decision is that the proximal clamp should be put above the left subclavian artery. If we cannot put it above the left subclavian artery we have to use deep hypothermic circulatory arrest for proximal anastomosis.
