Ascending aortic aneurysm following aortic valve replacement due to aortitis syndrome; report of a case

A 60-year-old woman had previously undergone aortic valve replacement for aortic regurgitation. As the aortic wall was elastic hard, inflammatory change was suspected; therefore, we undertook a partial biopsy of the ascending aortic wall and the intraoperative pathological specimens were compatible with aortitis syndrome. As there was no active inflammatory change, she was diagnosed as inactive aortitis syndrome and steroid therapy was not applied. Seven years later, a follow-up computed tomography (CT) showed an ascending aortic aneurysm of 65 mm in diameter. Aortic root replacement was planned based on a clinical diagnosis of an aneurysm of the ascending aorta. The patient was discharged without complication 21 days after surgery. It is possible that an inactive stage of aortitis may lead to late dilatation of the ascending aorta; therefore, careful postoperative follow-up is necessary in such cases.     

Interposition graft method in the treatment of aortic regurgitation associated with aneurysm of the ascending aorta

Interposition graft method, total replacement of the ascending aorta with a valved conduit and reimplantation of the coronary artery by an interposed graft with some modifications, had been exclusively used for the treatment of aortic regurgitation associated with an aneurysm of the ascending aorta in consecutive 7 cases. Clinical improvement is apparent and postoperative angiographic study revealed a satisfactory coronary and aortic appearance with no leakage, pseudoaneurysm formation nor compression of the graft. This technique proved to be a reliable and safe method for the treatment of aortic regurgitation associated with an aneurysm of the ascending aorta with no mortality nor modality.     

A false aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case

A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu’s arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438–445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.     

The surgical treatment of ruptured thoracic aortic aneurysm with use of permanent bypass

Two surgical cases with ruptured thoracic aortic aneurysm were reviewed. Case 1 was a 74-year-old female, and Case 2 was a 77-year-old female. In both cases, chest X-ray examination revealed a mass like shadow in the left superior mediastinum, and aortography demonstrated a ruptured saccular aneurysm distal to the left subclavian artery. Midsternotomy and an incision over the third left intercostal space were made to approach the aneurysm. Since inflammatory adhesion was marked in the perianeurysmal area, a permanent bypass was placed between the ascending and descending aorta followed by exclusion of the aneurysm. One of the two cases was alive, but the other case was died due to bleeding from the area of permanent aortic clamp.     

A case of ascending aortic dissection after aortic valve replacement in congenital bicuspid aortic valve]

Congenital bicuspid aortic valve is a risk factor of aortic dissection, but the case is rare in Japan. Several reports described ascending aortic aneurysm after aortic valve replacement. In these reports, most of aneurysms were false aneurysm, but the cases of ascending aortic dissection were rare. In this case, dissecting aneurysm of the ascending aorta occurred 4 years after aortic valve replacement, which was performed with mechanical prosthesis because of infective endocarditis, and it was repaired successfully by the modified Cabrol's method. This case was congenital bicuspid aortic valve, and had already been complicated with moderate aortic dilatation in the ascending aorta. In patients of congenital bicuspid aortic valve with aortic dilatation, consideration of complete replacement of the ascending aorta with aortic valve replacement is important.     

Complications after hybrid repair of aortic arch aneurysm

Hybrid repair can be an alternative to conventional open repair of aortic arch aneurysms especially in high risk cases. A 77 year male patient presented to us with complaints of breathlessness and chest pain. Investigations revealed aortic arch aneurysm with healthy ascending and descending aorta. Hybrid repair including supra aortic debranching and relocation of the arch vessels to the ascending aorta was performed. Complications like poststent-implant syndrome, cerebrovascular accident and localized dissection of ascending aorta at the site of stenting occurred.     

alpha-1抗胰蛋白酶在升主动脉夹层及瘤样扩张血管组织中的表达

目的 观察正常升主动脉、升主动脉瘤样扩张及Stanford A型夹层动脉瘤(TAAD)患者升主动脉血管组织中alpha-1抗胰蛋白酶表达的差异,探讨alpha-1抗胰蛋白酶对于维持升主动脉血管结构完整性中的作用.方法 收集28例升主动脉血管组织标本,TAAD 14例,升主动脉瘤样扩张7例,心脏移植供体心脏升主动脉7例.采用组织学、逆转录-聚合酶链反应(RT-PCR)法及Western blot 法对标本组织中的alpha-1抗胰蛋白酶进行检测分析.结果 在基因水平上,alpha-1抗胰蛋白酶在升主动脉瘤样扩张中表达最高,正常血管组织中表达次之,TAAD患者升主动脉中表达最低(2.192±0.133、1.213±0.156、0.672±0.101,P<0.05).在蛋白水平上,alpha-1抗胰蛋白酶在升主动脉瘤样扩张中表达明显升高,TAAD患者升主动脉中表达次之,正常血管组织中最低(0.285±0.010、0.153±0.011、0.102±0.010,P<0.05).结论 alpha-1抗胰蛋白酶在正常人、升主动脉瘤样扩张及TAAD患者升主动脉血管组织均有表达,表达差异有统计学意义.alpha-1抗胰蛋白酶对于维持升主动脉血管结构的完整性具有潜在的保护作用.     

Idiopathic inflammatory aneurysm of the ascending aorta

Inflammatory aneurysms of the ascending aorta are exceedingly rare. The principal cause of ascending aortic aneurysms remains arteriosclerosis. We present a patient with an ascending aortic aneurysm caused by active inflammatory disease superimposed on complex atherosclerotic disease of the aorta.     

Combined heart transplantation and resection of dissecting aneurysm of ascending aorta and aortic arch: a case report.

A 21-year-old male patient had suffered from palpitation and exertional dyspnea since October, 1997. He was admitted to our hospital, and a series of examinations were performed. Chest computed tomography (CT) revealed marked dilatation of the ascending aorta (about 7.5 cm at the proximal portion) and aortic annulus, an intimal flap in the ascending aorta and aortic arch was also noted. Cardiac catheterization revealed the pulmonary capillary wedge pressure was 33 mmHg, pulmonary artery pressure was 47/38 mmHg with a mean of 35.4. The cardiac index was 1.01 l/min/m2. Poor left ventricular contractility was shown by a left ventricular ejection fraction (LVEF) of 13.8% and a right ventricular ejection fraction (RVEF) of 5.13% by a radionuclide angiogram (RNA) study. Under the diagnosis of dilated cardiomyopathy and dissecting aortic aneurysm of the ascending aorta and aortic arch, he was put on a waiting list for heart transplantation. On November 11, 1997 he received heart transplantation. Resection of the dissecting aneurysm of the ascending aorta and the aortic arch and replacement with a 26 mm Vascutek graft were performed first under deep hypothermia and retrograde cerebral perfusion. Then while he was rewarming up, heart implantation was performed. He was discharged 30 days after surgery and has been doing well since then. As far as we know, no literature regarding combined heart transplantation and resection of a dissecting aneurysm of the ascending aorta and aortic arch has been reported.     

Aneurysm of the ascending aorta in its coarctation

In long-term period after resection of aorta coarctation, 9-14% patients developed aortic aneurysms, one third of them localized in the ascending aorta. From 146 patients operated on for aneurysm of the ascending aorta, 3 had aortic coarctation. In 2 patients aneurysms of the ascending aorta formed late after resection of the coarctation, the third patient was hospitalized with clinical picture of cardiac insufficiency at terminal stage due to coarctation of the aorta and a giant aneurysm of the ascending aorta with significant aortic insufficiency. The patients underwent successful surgeries: 1) ascending aorta grafting; 2) aortic valve and ascending aorta grafting by Bentallo de Bono method; 3) aortic valve and ascending aorta grafting by Bentallo de Bono method with bypass of descending aorta from the conduit. Cystic medianecrosis and two-volume aortic valve were revealed in all the patients. It is concluded that patients after surgery for coarctation of the aorta require long-term follow-up to defect cardiovascular complications early.     

Ruptured thoracic aortic aneurysm complicated by acute aortic dissection and aortic valve regurgitation; report of a case

An 87-year-old man was found loss of consciousness after falling. He was found in a state of shock. Computed tomography showed rupture of aneurysm of the ascending aorta and aortic arch with acute aortic dissection. Echocardiography revealed aortic valve regurgitation and cardiac tamponade. As the result of emergency operation, a large hematoma in the mediastinum and pleural cavity as well as massive serous pericardial effusion were found. The dissection was seen in aneurysm of the ascending aorta and aortic arch with an intimal tear located in the aortic arch. After aortic valve replacement was performed, the ascending aorta and aortic arch were replaced, and reconstruction of 3 cervical vessel branches was performed under deep hypothermic circulatory arrest with selective cerebral perfusion. Despite the complex clinical state and serious condition in the elderly patient, emergency surgery saved the life of the patient without complications.     

A successful surgical treatment of chronic traumatic mid-descending thoracic aortic aneurysm]

A 48-year-old woman with chronic mid-descending thoracic aortic aneurysm was successfully repaired. She received a blunt chest trauma due to automobile accident at July in 1988. Left upper lobectomy was performed for her lung contusion. March 1990, she admitted our hospital with abnormal shadow revealed by a chest roentgenogram. A computed tomogram of the chest and an aortogram revealed two false aneurysms. One of them was located at mid-descending thoracic aorta and another was aortic isthmus. Under a partial femoral veno-arterial bypass, a Dacron graft replacement of mid-descending thoracic aorta was performed and aneurysm of isthmus was wrapped by Teflon mesh after the left pneumonectomy. 2 months after the operation, bronchopulmonary fistula occurred at the left bronchial stump. The fistula was successfully covered with major omentum. The mid-descending thoracic aortic aneurysm due to blunt chest trauma is rare. The traumatic aortic aneurysms commonly occur aortic isthmus or ascending aorta. Initial diagnosis of traumatic mid-descending thoracic aortic aneurysm is often missed or delayed. Careful follow up is need and when an abnormality is revealed by chest roentgenogram, computed tomogram and aortogram should be obtained to make diagnosis of chronic traumatic aneurysm.     

Aneurysm of the left sinus of Valsalva producing obstruction of the left main coronary artery and aortic regurgitation

A 50-year-old male was admitted with dyspnea on exertion and palpitation. On physical examination, a grade 2/6 aortic regurgitant murmur was heard at the left sternal border. A chest roentogenogram showed an oval shadow on the left cardiac border. Digital subtraction angiogram, aortogram and coronary arteriogram revealed an unruptured-large aneurysm of the left sinus of Valsalva, which compressed the left main coronary artery and produced aortic regurgitation. Surgical correction consisted of obliteration of the orifice of the aneursym with woven Dacron graft patch, aortic valve replacement using SJM23A, and a saphenous vein bypass from the ascending aorta to the left anterior descending coronary artery. Postoperative studies showed complete obliteration of the orifice of the aneurysm, a patent aorto-coronary bypass graft and no perivalvular leakage. This aneurysm was considered congenital in origin, because of no inflammatory and infectious evidence, negative serologic test for syphilis and no aneurysmal dilatation of the ascending aorta.     

Arch translocation method for an arch aneurysm with open stent grafting using a nephrostomy catheter

An 81-year-old female found to have an aneurysm in the distal aortic arch was successfully treated with arch translocation method. Under selective cerebral perfusion, a stent graft bound to a nephrostomy balloon catheter with a chainstitch was inserted from the ascending aorta into the descending aorta and its proximal end was sutured together with the distal aortic stump. Then a 4-branched Dacron graft replaced the ascending aorta reconstructing cephalobracheal branches individually. Each proximal end of cephalobracheal branches was ligated. The patient had no neurological deficit except for recurrence nerve palsy that had already existed before the operation. Postoperative angiography revealed complete thrombocclusion of the aneurysm.     

Surgical technologies in the treatment of aneurysms of thoracic and thoraco-abdominal aorta

From 1993 to 2001 279 patients with aneurysms of the thoracic and thoracoabdominal aorta were operated. Cause of aneurysm formation in 74% cases was degenerative changes of aortal wall (Marfan's disease or Erdheim syndrome). Aneurysms were revealed in ascending aorta in 38 (14%) cases, in the ascending aorta with insufficiency of aortic valve--in 67 (24%), in the ascending aorta and aortic arch--31 (11%), in descending aorta--54 (19%), thoracoabdominal aneurysms--in 89 (32%). Twenty patients underwent surgery for combined aneurysms of the ascending aorta with it arch and descending part, thoracoabdominal aneurysms, and also for thoracic aneurysms in combination with coronary heart disease. Lethality in early postoperative period in patients with aneurysms of the ascending aorta was 5%, with aneurysms of the ascending aorta and insufficiency of the aortic valve--6.2%, in aneurysms of the ascending aorta and aortic arch--16.2%, in aneurysms of the descending aorta--6.4%, in thoracoabdominal aneurysms--15%.     

Spontaneous rupture of the ascending aorta

A case of spontaneous non-traumatic rupture of the thoracic aorta in a hypertensive patient is presented. The clinical findings suggested acute aortic dissection, and a large pericardial effusion was detected by echocardiography. The typical angiographic features of aortic dissection were not found. Autopsy revealed a longitudinal intimal tear and a rupture in the postero-lateral aspect of the ascending aorta. No false lumen was seen in the ascending aorta. When acute intrapericardial or intrapleural bleeding develops with no evidence of aortic aneurysm or dissection, spontaneous aortic rupture should be suspected.     

Unusual false aneurysm of the ascending aorta associated with ruptured acute type A aortic dissection

Abstract   False aneurysm of the thoracic aorta unrelated to trauma, or to previous aortic or cardiac surgery, is extremely rare. We encountered a case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection. The false aneurysm, which was contained by thin connective tissue surrounding the aortic wall, was located beside the false lumen of the dissected ascending aorta, expanding toward the transverse sinus. We immediately decided to perform an emergency operation. We noted the large entry site at the anterior wall of the dissected ascending aorta after resection of the flap. We identified the false aneurysm arising from a small tear of the false lumen. Graft replacement of the ascending aorta using a tube graft was performed. The postoperative course was satisfactory. This pathology was believed to be not only a consequence of hemostasis, but also a process of re-rupture of the dissected aorta.     

Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries

From November, 1976, to June, 1983, 100 patients, 84 male and 16 female patients ranging in age from 13 to 74 years, were operated on for aortic insufficiency associated with an aneurysm of the ascending aorta. Twenty patients were in New York Heart Association Class I, 22 in Class II, 51 in Class III, and seven in Class IV. The surgical treatment in all cases consisted of total replacement of the ascending aorta with a tube graft containing a prosthetic aortic valve and reimplantation of the coronary arteries by an intermediate tube graft according to the technique already reported. In 68 patients an uncomplicated annulo-aortic ectasia existed, and in 32, an aortic dissection; nine of the latter group were operated on during the acute phase. The operative mortality for the entire group was 4% (four deaths). One patient has been lost to follow-up during a period ranging from 18 months to 8 years (average 54 months). The late mortality has been 11/96. Among the 84 survivors, clinical improvement is readily apparent (89% are in Class I or II). Twenty-five patients have been restudied by angiography, which revealed a satisfactory coronary and aortic appearance in all cases with neither stenosis nor aneurysm. The actuarial survival rate is 75% at 8 years. In conclusion, the treatment of aortic insufficiency associated with an aneurysm of the ascending aorta by insertion of a composite graft and reimplantation of the coronary arteries through an intermediate Dacron tube is a reliable method with low mortality and excellent long-term results.     

Saccular True Aneurysm of the Ascending Aorta 19 Years After Aortic Cannulation: Report of a Case

A 61-year-old woman who had undergone surgery for a right ventricular myxoma 19 years earlier was admitted to our hospital for treatment of a saccular aneurysm of the ascending aorta at the site of the previous aortic cannulation. We resected the aneurysm completely and closed it with a polyester patch. Pathologic examination revealed an aortic wall saccular aneurysm, without atherosclerotic changes or bacterial cultures, consisting of elastic fibrous tissue and artificial material. There were inflammatory changes at the top of the aneurysm, with continuity of medial elastic fibrous tissue inside. These pathological findings strongly suggested a true aneurysm with continuity of medial elastic fibrous tissue. We report this extremely unusual case of a saccular true aneurysm at a previous aortic cannulation site.     

Survival in Thoracic or Thoracoabdominal Aortic Aneurysm: Comparison between patients with or without surgical treatment

The surgical mortality among 22 patients treated for thoracic or thoracoabdominal aneurysm was compared with the mortality in 47 patients managed without surgery. Surgical mortality (<30 days) was low (1/13) in ascending aortic aneurysm, but higher (3/8) in aneurysm of the descending or thoracoabdominal aorta (including both acute and elective operations). Of the 20 non-surgically managed patients in the latter group, 15 died after a mean of 1.1 year. The only patient operated on for aortic arch aneurysm died of cerebral ischaemia 2 days postoperatively. Most of the 19 non-operated patients with aneurysm of the arch or total aorta (mean age 76 years) were never considered for surgical treatment. The analysis supports aggressive management of patients with aneurysm of the ascending, descending or thoracoabdominal aorta. Many of our patients with aneurysm of the arch or involving most of the aorta were old and had other, concomitant diseases, and in such cases an aggressive treatment strategy does not seem justified.