Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Fate of aneurysms of the distal arch and proximal descending thoracic aorta after transaortic endovascular Stent-Grafting

BACKGROUND: The purpose of this study was to evaluate the midterm results of transaortic stent-grafting for distal aortic arch aneurysms or proximal descending aortic aneurysms and the feasibility of this method for thoracic aortic aneurysm repair. METHODS: Twenty-three patients with true distal aortic arch aneurysms or proximal descending thoracic aortic aneurysms were repaired with the stent-graft introduced through the incision on the proximal arch aorta. Follow-up computed tomography was performed every 6 months in 21 surviving patients. The maximum dimension of the excluded aneurysmal space and the maximum aneurysmal diameter were measured and evaluated to determine whether the aneurysmal space decreased or disappeared after this alternative procedure. RESULTS: There was 1 hospital death (4.3%) due to cerebral embolism. Another patient died of pneumonia 1 year after surgery. Twenty-one patients (91%) survived during the follow-up period, but 1 patient (4.3%) suffered from paraplegia. The follow-up period ranged from 12 to 62 months (average, 34.3 +/- 15.2). There were no instances of aneurysmal rupture during the follow-up period. Postoperative serial computed tomography scans showed disappearance or significant shrinkage of the excluded aneurysmal space in 20 of 21 patients (95%), except for the one patient with endoluminal leakage. CONCLUSIONS: Transaortic endovascular stent-grafting was an effective alternative approach to treating distal aortic arch aneurysms or proximal descending aortic aneurysms. The excluded aneurysm disappeared or shrunk after successful placement of the stent-graft.     

Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size

BACKGROUND: Prior work has clarified the cumulative, lifetime risk of rupture or dissection based on the size of thoracic aneurysms. Ability to estimate simply the yearly rate of rupture or dissection would greatly enhance clinical decision making for specific patients. Calculation of such a rate requires robust data. METHODS: Data on 721 patients (446 male, 275 female; median age, 65.8 years; range, 8 to 95 years) with thoracic aortic disease was prospectively entered into a computerized database over 9 years. Three thousand one hundred fifteen imaging studies were available on these patients. Five hundred seventy met inclusion criteria in terms of length of follow-up and form the basis for the survival analysis. Three hundred four patients were dissection-free at presentation; their natural history was followed for rupture, dissection, and death. Patients were excluded from analysis once operation occurred. RESULTS: Five-year survival in patients not operated on was 54% at 5 years. Ninety-two hard end points were realized in serial follow-up, including 55 deaths, 13 ruptures, and 24 dissections. Aortic size was a very strong predictor of rupture, dissection, and mortality. For aneurysms greater than 6 cm in diameter, rupture occurred at 3.7% per year, rupture or dissection at 6.9% per year, death at 11.8%, and death, rupture, or dissection at 15.6% per year. At size greater than 6.0 cm, the odds ratio for rupture was increased 27-fold (p = 0.0023). The aorta grew at a mean of 0.10 cm per year. Elective, preemptive surgical repair restored life expectancy to normal. CONCLUSIONS: This study indicates that (1) thoracic aneurysm is a lethal disease; (2) aneurysm size has a profound impact on rupture, dissection, and death; (3) for counseling purposes, the patient with an aneurysm exceeding 6 cm can expect a yearly rate of rupture or dissection of at least 6.9% and a death rate of 11.8%; and (4) elective surgical repair restores survival to near normal. This analysis strongly supports careful radiologic follow-up and elective, preemptive surgical intervention for the otherwise lethal condition of large thoracic aortic aneurysm.     

Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta

PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients.     

Mechanical deterioration underlies malignant behavior of aneurysmal human ascending aorta

OBJECTIVE: The human ascending aorta becomes markedly prone to rupture and dissection at a diameter of 6 cm. The mechanical substrate for this malignant behavior is unknown. This investigation applied engineering analysis to human ascending aortic aneurysms and compared their structural characteristics with those of normal aortas. METHODS: We measured the mechanical characteristics of the aorta by direct epiaortic echocardiography at the time of surgery in 33 patients with ascending aortic aneurysm undergoing aortic replacement and in 20 control patients with normal aortas undergoing coronary artery bypass grafting. Six parameters were measured in all patients: aortic diameter in systole and diastole, aortic wall thickness in systole and diastole, and blood pressure in systole and diastole. These were used to calculate mechanical characteristics of the aorta from standard equations. Aortic distensibility reflects the elastic qualities of the aorta. Aortic wall stress reflects the disrupting force experienced within the aortic wall. Incremental elastic modulus indicates loss of elasticity reserve. RESULTS: Aortic distensibility falls to extremely low levels as aortic dimension rises toward 6 cm (3.02 mm Hg(-1) for small aortas versus 1.45 mm Hg(-1) for aortas larger than 5 cm, P < .05). Aortic wall stress rises to 157.8 kPa for the aneurysmal aorta, compared with 92.5 kPa for normal aortas. For 6-cm aortas at pressures of 200 mm Hg or more, wall stress rises to 857 kPa, nearly exceeding the known maximal tensile strength of human aneurysmal aortic wall. Incremental elastic modulus deteriorates (1.93 +/- 0.88 MPa vs 1.18 +/- 0.21 MPa, P < .05) in aneurysmal aortas relative to that in normal aortas. CONCLUSION: The mechanical properties of the aneurysmal aorta deteriorate dramatically as the aorta enlarges, reaching critical levels associated with rupture by a diameter of 6 cm. This mechanical deterioration provides an explanation in engineering terms for the malignant clinical behavior (rupture and dissection) of the aorta at these dimensions. This work adds to our fundamental understanding of the biology of aortic aneurysms and promises to permit future application of engineering measurements to supplement aneurysm size in clinical decision making in aneurysmal disease.     

Thoracic aortic aneurysm associated with congenital bicuspid aortic valve.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1981 and August 1997, 25 patients with an aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at the authors' institution. There were 20 males and five females. The age of the patients ranged from 27 to 74 years (mean 53 years). There were 18 patients with true ascending aortic aneurysms (of which 10 presented with annulo-aortic ectasia) and seven with dissecting aortic aneurysms (four with DeBakey type I dissection, two with type II and one with type IIIb). These 25 patients constituted 2.6% (25/973) of all cases of surgical operations for aneurysms in the thoracic aorta. Aortic valve dysfunction was noted in 20 patients. The authors performed a valved conduit operation in nine patients, aortic valve replacement and wrapping of the ascending aorta in six, graft replacement of the ascending aorta in five, graft replacement of the ascending aorta and aortic arch in four, and graft replacement of the descending aorta in one. No hospital deaths occurred in the authors' patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 11 patients and mucoid degeneration in nine. In patients with congenital bicuspid aortic valve, attention should be paid to aneurysmal dilatation and aortic dissection as complications in addition to valve dysfunction.     

Natural history of descending thoracic and thoracoabdominal aortic aneurysms

ObjectivesElucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes.MethodsAortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan–Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated.ResultsEstimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm.ConclusionsAcute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.     

Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation.

The life expectancy of patients with aortic aneurysm is significantly prolonged by graft replacement therapy. Regardless, a significant predictor of late death is complications of either residual aortic aneurysmal disease or the development of additional aortic aneurysm. This paper reviews a personal experience in the treatment of 4170 patients with aneurysmal disease of either dissection or medial degenerative origin, indicating that multiple segment involvement was or became present in 1262 (30%) patients, 463 (67%) of 694 patients with dissection, and 799 (23%) of 3476 patients without dissection. Regardless of etiology, multiple involvement varied with the location of the presenting involved segment, i.e., ascending aorta (38%), ascending and arch (70%), descending thoracic aorta (73%), and abdominal aorta (26%). This study was limited in detail to 811 patients who had ascending and ascending and aortic arch replacement for aneurysm. These patients were divided into 3 subgroups: (1) 524 patients with no distal disease; (2) 135 patients with distal disease treated by subtotal replacement in 82 and total replacement in 53; and (3) 152 patients with distal disease not treated. The 5-year survival rate from the time of first operation, including early death from operation was 75% in group 1, 65% in group 2, and 39% in group 3. The causes of death in group 3 patients were aneurysmal rupture and/or associated disease. It is concluded that initial total aortic study and regular postoperative monitoring with computed tomographic scanning is indicated to detect extensive disease or recurrence of disease and that aggressive replacement is indicated except in patients with associated disease that does not permit operation.     

Spontaneous nontraumatic rupture of the thoracic aorta: report of a case

Spontaneous nontraumatic rupture of the thoracic aorta is a very rare, life-threatening condition for which emergency diagnostic and therapeutic measures are indicated. The patient reported herein suffered a spontaneous rupture of the thoracic descending aorta through an atheromatous plaque without aneurysmal formation. When acute intrapericardial, mediastinal, or intrapleural bleeding develops without any evidence of aortic aneurysm or dissection, the possibility of spontaneous rupture of the thoracic aorta should be considered in the differential diagnosis, and appropriate emergency surgery may be life-saving. Received: April 17, 2000 / Accepted: March 6, 2001     

Ruptured giant syphilitic aneurysm of the descending aorta in an octogenarian

Syphilis can lead to saccular aneurysms of the thoracic aorta. Today syphilitic aortic aneurysms are rare. The average time from primary infections to the development of aortic aneurysms is 10 to 15 years. An 83-year-old man was admitted with a giant aneurysm of the descending thoracic aorta. The patient had first experienced subacute pain in the left hemithorax some weeks previously. Computer tomography scan detected an 11 x 11 cm aneurysm of the descending aorta. Serodiagnostic tests for syphilis were highly positive. Femoro-femoral bypass was initiated and a tube graft was interposed. The postoperative course was uneventful, the patient was discharged at the twentieth postoperative day. Histological examination of the aneurysmal wall showed typical syphilitic changes. Postoperatively, Penicillin G was given for 6 months. Three years later the patient remains asymptomatic. Although extremely rare today, tertiary syphilis should be considered in the differential diagnosis of thoracic aneurysms. In selected octogenarians replacement of the descending aorta is possible.     

Surgical repair of dissection of the upper descending thoracic aorta and discrete ascending aortic aneurysm.

This report describes successful staged surgical repair in 2 patients with dissection of the upper descending thoracic aorta (DeBakey type III) with coexisting discrete Marfan's aneurysms of the ascending aorta. Initial repair of the descending aortic dissection was done through a left thoracotomy using a transverse aorta--femoral artery shunt in 1 patient and a left ventricular apex--femoral artery shunt without systemic heparinization in the other. Emphasis is placed on the need for pharmacological reduction of blood pressure during aortic cross-clamping as well as the use of a shunt to prevent dissection of the ascending aortic aneurysm. In both patients, subsequent repair of the ascending aortic aneurysm was accomplished using composite graft replacement of the aortic valve and ascending aorta. This operation is advised for such patients even in the absence of notable aortic valve incompetence.     

胸主动脉夹层合并腹主夹层动脉瘤的一期腔内治疗

目的：探讨胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤病人一期腔内隔绝术治疗的可行性、手术操作技巧及并发症防治原则。方法和结果：1例Stanford B型胸主动脉夹层动脉瘤合并腹主动脉夹层动脉瘤及双侧髂动脉瘤的病人于2006年3月在本中心接受了腔内隔绝术。MRA检查提示．主动脉弓降交界处开始出现夹层．真腔受压变窄,以胸腹交界处及腹主动脉中段最明显,最扁窄处为0．5cm;假腔在腹主动脉中段明显,最大径约5．0cm,假腔再人口位于左髂总动脉近端。双侧髂总动脉迂曲并呈瘤样扩张。腹腔干、肠系膜上动脉及双侧肾动脉均发自真腔。手术在全麻下进行：降主动脉植入规格为34-34-100mm的直管型Talent移植物,封闭夹层裂口：腹主动脉植入规格为AOI26-12-170mm Talent移植物,远端连接12．12．68mmTalent移植物至一侧髂外动脉,行双侧股-股转流。瘤体隔绝完全,手术约耗时300min,失血1000ml,透视6min,使用威视派克450ml。术后21d出院。术后随访半年,病人生活质量良好,复查CTA显示：移植物通畅,瘤腔内均完全形成血栓。结论：腔内隔绝术的微创特点使一期治疗Stanford B型主动脉夹层动脉瘤合并腹主动脉瘤成为一种比较安全的手术。主动脉长段隔绝也有利于降低截瘫的发生率。     

Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta

BACKGROUND: Aneurysms of the ascending, arch, and descending thoracic aorta are typically managed with two operations. The first stage involves replacement of the ascending and arch aorta leaving a segment of graft in the proximal descending aorta with a mortality and stroke risk of 8%. The second stage involves replacement of the descending aorta with a mortality of 5% and a paraplegia risk of 5% to 10%. Some patients refuse surgical completion and others are at increased risk to undergo the second stage thoracotomy, leaving them with untreated descending thoracic aortic aneurysms vulnerable to rupture. A single-stage transmediastinal operation used in 14 patients is described. METHODS: Under circulatory arrest, the descending thoracic aorta is opened. A wire is passed up to the arch and a graft is brought down and secured excluding the descending thoracic aneurysm. The arch vessels are attached as a single patch and the graft is brought forward, replacing the ascending aorta. RESULTS: Fourteen patients have undergone single-stage replacement of the ascending, arch, and descending aorta with a 14% mortality rate and 14% incidence of paraplegia. CONCLUSIONS: Patients with aneurysms of the ascending, arch, and descending thoracic aorta can be managed with a single operation with comparable mortality and morbidity of the two-stage approach.     

Diagnosis and treatment of thoracic aortic intramural hematoma

Purpose: This report reviews our recent experience with nine patients who had intramural hematoma of the thoracic aorta.Methods: This was a retrospective study of all patients who had intramural hematoma at our institution from 1989 to 1994. Patients who had identifiable intimal flap, tear, or penetrating aortic ulcer were excluded from the study.Results: Among these nine elderly patients (mean age, 76 years), the most common presentation was chest or back pain. Intramural hematoma was diagnosed by a variety of high-resolution imaging techniques. The descending thoracic aorta alone was involved in seven patients, whereas the ascending aorta was affected in the other two patients. One patient had evidence of an aneurysm (5.0 cm diameter) in the region of the hematoma. All patients were initially managed nonsurgically with blood pressure control. Both patients who had ascending aortic involvement had progression of aortic hematoma, which resulted in death in one case and in successful surgery in the other. Six of the seven patients who had descending aortic involvement alone were successfully managed without aortic surgery. The patient who had intramural hematoma and associated aortic aneurysm, however, had severe, recurrent pain and underwent successful aortic replacement. Another patient had recurrent pain associated with hypertension, but was successfully managed nonsurgically with antihypertensive therapy. All eight survivors are doing well at a median follow-up of 19 months.Conclusions: Intramural hematoma appears to be a distinct entity, although overlap with aortic dissection or penetrating aortic ulcer exists. Aggressive control of blood pressure with intensive care unit monitoring has been our initial management. Patients who have involvement of the descending thoracic aorta alone can frequently be managed without surgery in the absence of coexisting aneurysmal dilatation or disease progression. Our experience suggests that a more aggressive approach with early surgery is warranted in patients who have ascending aortic involvement or those who have coexisting aneurysm and intramural hematoma. (J Vasc Surg 1996;24;1022-9.)     

Endovascular repair of a ruptured descending thoracic aortic aneurysm in a patient with an ascending aortic aneurysm: hybrid open arch reconstruction with simultaneous thoracic stent-graft deployment within elephant trunk

Endovascular repair of the thoracic aorta is now widely practiced. The extension of this technique to emergent settings is in evolution. Pathology of the ascending and transverse aortic arch may preclude thoracic aortic stent grafting due to the lack of a proximal seal zone. Several hybrid open/endovascular approaches have been described. We recently encountered the difficult case of a contained rupture of a 6.8 cm descending thoracic aortic aneurysm in a 60-year-old patient with aneurysmal degeneration of the ascending and transverse aortic arch. This patient was treated with a hybrid approach of open ascending and transverse arch reconstruction along with simultaneous stent-graft repair of the descending thoracic aorta. The open repair established an excellent proximal landing zone by use of the "elephant trunk" technique. This technique also allowed direct suture fixation of the stent graft to the arch graft to prevent stent-graft migration. This hybrid surgical approach was successful and avoided the cumulative morbidity that a left thoracoabdominal approach would have added to the sternotomy. Further creative uses of these hybrid techniques will undoubtedly serve a larger role in the treatment of thoracic aortic pathology.     

“Descending aortic aneurysm with acute type III dissection in a postpartum patient”

Acute aortic dissection and rupture of aneurysm is quite rare in the young. A 26-year-old woman (non-Marfan) presented with anemia and massive left sided hemothorax in her early postpartum period. She was diagnosed to have acute Type III aortic dissection with rupture of thoracic aortic aneurysm. A very small and unhealthy descending thoracic aorta precluded any usual repair and she underwent an ascending aortaabdominal aorta bypass graft. Histopathological features of the aorta were suggestive of aortoarteritis (Takayasu’s).     

Combined surgical and endovascular treatment of extensive thoracic aortic aneurysm

AIM: Patients with extensive aneurysm involving ascending aorta, aortic arch and descending aorta are usually treated by sequential operations. For these patients we can also use combined surgical and endovascular treatment. The experience with this procedure published in the literature is very limited. We report our experience in the 'elephant trunk' technique followed by an endovascular stent-grafting of the descending thoracic aorta in a small group of three consecutive patients with extensive thoracic aortic aneurysm. METHODS: Three consecutive patients with extensive thoracic aortic aneurysm or chronic dissection underwent combined surgical and endovascular treatment between January and December 2004. The procedure was carried out as a two-stage procedure. During the first stage aortic arch was replaced using the elephant-trunk' method and during the second stage the stentgrafting of the descending aorta was performed. RESULTS: All three patients were treated successfully. There was no death, no endoleak and no permanent neurological deficit. One patient had a transient paraparesis. In all patients the spiral CT demonstrated excellent technical result without endoleak and with thrombosis of the paraprosthetic space. CONCLUSIONS: We can conclude, that the combined surgical and endovascular treatment of extensive thoracic aortic aneurysm is a feasible method which could reduce mortality and morbidity. In our institution the elephant trunk technique followed by an endovascular stent-grafting of the descending aorta is the preferred method of treatment in patients with extensive thoracic aortic aneurysm involving ascending aorta, aortic arch and descending aorta.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.     

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%.     

Delayed retrograde aortic dissection after endovascular stenting of the descending thoracic aorta

A 66-year-old patient underwent emergency endovascular repair of a descending thoracic aneurysm because of suspected aortic rupture. Two weeks later, a small saccular aneurysm of the aortic arch was treated with open surgery. An unexpected intraoperative finding was retrograde dissection of the aortic arch and of the ascending aorta that was not seen on the postprocedural computed tomographic scans after endografting. The ascending aorta, the aortic arch, and the proximal part of the descending thoracic aorta were successfully replaced with a Dacron graft with deep hypothermia, circulatory arrest, and retrograde cerebral perfusion. Awareness that this life-threatening complication that necessitates extensive cardiovascular surgery can occur not only during or immediately after endovascular stenting of the thoracic aorta but also as much as several days or perhaps even weeks after the procedure is important.