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.     

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.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.     

Double aortic arch with aneurysm-a surgical case report.

An unusual case of double aortic arch with aneurysm is described. A 61-year-old, hypertensive and syphilitic male patient complained of increasing difficulty in swallowing of approximately five months duration. Barium swallow and subsequent aortography showed the presence of an aneurysm of the ascending aorta involving the left (anterior) arch of the double aortic arch. The tightening of the vascular ring by aneurysmal dilatation of the left aortic arch appeared to be responsible for the delayed onset of the symptom. Surgical correction was made by removing the aneurysmal ascending aorta and left aortic arch and a Dacron graft was inserted between the ascending aorta and the right (posterior) aortic arch. The patient died of cerebral complication about forty hours postoperatively. Surgical problems associated with this unusual condition were discussed retrospectively from the operative and autopsy findings. In reviewing the pertinent literatures this case appeared to be the first operated case of double aortic arch associated with aneurysm.     

A successful surgical case of aortic arch aneurysm associated with aortic regurgitation

A 57-year-old male patient with aortic regurgitation and aneurysm of the ascending aorta and the aortic arch underwent aortic valve replacement and graft replacement from the ascending aorta to the aortic arch. The operation was done using cardio-pulmonary bypass and selective cerebral perfusion with deep hypothermia. Postoperative DSA revealed no dilatation of the sinus Valsalva and a good configuration of the anastomosis. It seems that selective cerebral perfusion with deep hypothermia is a safe method to prevent cerebral damage in a case of arch aneurysm.     

Composite graft replacement after aortic valvuloplasty in Takayasu arteritis

A 24-year-old woman had undergone valvuloplasty of the aortic valve and external reinforcement of an aneurysm of the ascending aorta during the active phase of Takayasu arteritis 1 year prior to admission to our hospital. On examination, she was diagnosed as having a large false aneurysm of the ascending aorta with annuloaortic ectasia and severe aortic regurgitation, bilateral common carotid artery aneurysms with a left internal carotid artery saccular aneurysm, and bilateral subclavian artery and right vertebral artery obstructions due to Takayasu arteritis. Because of the risk of rupture, surgical intervention was carried out in spite of the fact that aortitis was in the active phase.     

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.     

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 case of Stanford type A acute aortic dissection complicated with clotted false lumen and saccular aneurysm formation]

A 59-year-old farmer was admitted with severe anterior chest and back pain. As MRI showed a Stanford type A dissection, operation was performed. Surgical intervention revealed the clotted false lumen of the ascending aorta without intimal tear, and it was transected and primarily reconstructed with Teflon felt bolsters. Three months later MRI disclosed disappearance of the dissected lumen in the ascending and descending aorta. During the following two years and three months, a saccular aneurysm of the distal arch was found to be increased in size rapidly. The second operation was attempted to close the intimal defect with patch. As a whole this was a rare case of DeBakey type III acute aortic dissection complicated with proximal extension, clotted false lumen and saccular aneurysm formation at the site of the intimal tear.     

Double aortic arch with aneurysm—A surgical case report

An unusual case of double aortic arch with aneurysm is described. A 61-year-old, hypertensive and syphilitic male patient complained of increasing difficulty in swallowing of approximately five months duration. Barium swallow and subsequent aortography showed the presence of an aneurysm of the ascending aorta involving the left (anterior) arch of the double aortic arch. The tightening of the vascular ring by aneurysmal dilatation of the left aortic arch appeared to be responsible for the delayed onset of the symptom. Surgical correction was made by removing the aneurysmal ascending aorta and left aortic arch and a Dacron graft was inserted between the ascending aorta and the right (posterior) aortic arch. The patient died of cerebral complication about forty hours postoperatively. Surgical problems associated with this unusual condition were discussed retrospectively from the operative and autopsy findings. In reviewing the pertinent literatures this case appeared to be the first operated case of double aortic arch associated with aneurysm.     

A case of ruptured aneurysm of the thoraco-abdominal aorta associated with Beh?et's disease

A 41-year-old male with incomplete type of Beh?et's disease was operated on because of ruptured aneurysm of the thoraco-abdominal aorta. A saccular pseudoaneurysm developed by rupture of the aortic wall involved the left postero-lateral portion of the supra-renal abdominal aorta. The defect in the aneurysm was closed using Dacron patch. The post-operative course was uneventful. However, seven months after discharge, the patient developed severe back pain at midnight, and was referred to our institution. On physical examination, a pulsatile mass was found in the right epigastric area. CT and DSA showed saccular pseudoaneurysm at the patch anastomotic site. Extra-anatomic long bypass grafting was performed from the ascending aorta to the infra-renal abdominal aorta. The abdominal aorta was occluded just below the diaphragm and the supra-renal portion of the aorta. Reconstruction of coeliac artery and superior mesenteric artery was made using branch grafts attached to the long graft. Surgical treatment of the complicated Beh?et's disease should include extra-anatomic bypass, especially in the re-operative cases of ruptured aneurysm of the aorta.     

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

Multiple atherosclerotic aneurysms of the bilateral subclavian artery, aortic arch and abdominal aorta.

Subclavian artery aneurysms are relatively rare in comparison with other peripheral aneurysms. We report a 65-year-old woman with multiple atherosclerotic aneurysms of the subclavian artery, aortic arch saccular aneurysm and abdominal aortic aneurysm. Two-staged operations by which the infrarenal abdominal aorta was replaced first and median sternotomy extending to the supraclavicular space for the concomitant resection of bilateral subclavian as well as aortic arch aneurysm resulted in good results.     

Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta

OBJECTIVE: Cerebral complication is still a major concern in surgery for arteriosclerotic aortic arch disease. For preventing this complication, axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and arch aorta were applied to thoracic aortic aneurysm involving aortic arch. METHOD: From May 1999 to July 2002, consecutive 39 patients with true aneurysm (29 patients) or chronic aortic dissection (10 patients) involving aortic arch underwent replacement of the ascending and arch aorta with an elephant trunk under hypothermic cardiopulmonary bypass through the axillary artery cannulation and selective cerebral perfusion. The brain was continuously perfused without any intermission through the axillary artery. Concomitant operation included coronary artery bypass grafting (CABG) in two patients, aortic valve replacement (AVR) in one, Bentall operation in two, mitral valve replacement (MVR) in one, and aortic valve sparing operation in one. Patient age at operation was 40-84 (72 + 9) years and 24 of them were older than 70 years of age. RESULTS: There was one operative death (2.5%) due to bleeding from the left lung, and one hospital death due to respiratory failure. Postoperative permanent neurological dysfunction was found in one patient (2.5%). Two patients presented temporary neurological dysfunction (5%). Thirty-six of the 39 patients were discharged from hospital on foot. CONCLUSION: Continuous perfusion through the axillary artery with selective cerebral perfusion and replacement of the ascending and arch aorta may minimize cerebral complication leading to satisfactory results in patients with chronic aortic aneurysm involving aortic arch.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

一期次全或全主动脉替换术的中期随访结果

目的 总结一期全主动脉替换术治疗全程主动脉瘤的中期随访结果.方法 2004年2月至2008年7月22例全程主动脉瘤的患者接受一期次全(7例)或全主动脉替换术(15例).男性17例,女性5例,年龄19～47岁.慢性A型夹层动脉瘤15例,主动脉根部瘤合并慢性B型夹层动脉瘤5例,主动脉根部瘤合并弓部和胸腹主动脉瘤1例,慢性B型合并急性A型夹层动脉瘤1例.手术均在全身麻醉深低温停循环顺行性脑灌注下进行.采用胸骨正中切口+左后外胸腹联合切口.采用分段阻断法用人工血管置换全部病变主动脉.结果 无手术死亡病例.术后早期死亡1例,死于多器官功能衰竭.术后发生脑梗死2例,二次开胸止血7例.存活21例,随访3～56个月,平均(35.0±16.9)个月,情况良好,无晚期死亡.1例David+全主动脉替换术患者术后1年因主动脉瓣反流行主动脉瓣置换术.此外无再手术病例.结论 一期次全或全主动脉替换术是治疗全程主动脉瘤的有效方法.手术结果满意,术后中期随访效果良好.     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

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.     

Dissecting Aortic Aneurysms

Anatomically, dissecting aneurysms may be classified into four types: Type I, the most common, originates in the ascending aorta or aortic arch and extends into the descending thoracic aorta and beyond. Type II, the rarest, is confined to the ascending aorta and proximal aortic arch. Type III begins in the proximal descending aorta and extends distally; this type has the best prognosis. Type IV, a newly proposed addition to these three, is an iatrogenic retrograde dissection of the aorta which originates in the iliac or femoral arteries during extracorporeal circulation by the transfemoral route.Drug therapy currently is the treatment of choice for all types of acute dissections except those of type IV. Immediate operation is reserved for good-risk patients with type I lesions, all patients with type IV dissections, complicated cases, or patients in whom drug therapy is contraindicated. In the chronic stage, operation is indicated when the patient develops a saccular aneurysm, marked aortic insufficiency, recurrent symptoms of pain, or enlargement of the aneurysm.