Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Repair of Mycotic Aneurysms of the Aorta Involving the Aortic Valve

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis.In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.     

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.     

Management of Ascending Aortic Aneurysm Complicating Coarctation of the Aorta

Four patients with coarctation of the aorta complicated by an aneurysm of the ascending aorta are described. One patient, treated only medically, died suddenly. For the 3 patients who underwent operation, management was similar. Pharmacological control of blood pressure and repair of the aortic coarctation to achieve anatomical reduction in afterload (stage I) were followed after an interval of one to five weeks by surgical repair of the ascending aortic aneurysm (stage II).Initial repair of the coarctation relieves proximal hypertension, thereby decreasing the chance of progressive dissection or rupture of the aneurysm. It also permits safe arterial cannulation for perfusion during correction of the aneurysm in the second stage. In patients not requiring valve replacement in stage II, continued long-term follow-up for progression of aortic valvular disease appears to be necessary.     

Aortic insufficiency secondary to aortic root aneurysm or dissection.

Twenty-four patients with aortic regurgitation secondary to aortic root aneurysm (13 patients) or dissection (11 patients) were operated on, utilizing a variety of surgical procedures to cope with the varied pathological findings. These ranged from primary repair of the ascending aorta without any prostheses in patients with acute aortic dissection to replacement of the valve and the entire ascending aorta for aortic root aneurysm. In four patients with Marfan syndrome the right coronary artery was transplanted to the ascending aortic graft, allowing an extension of the graft to the valve anulus and excision of the entire aneurysmal aorta. The immediate and late results have been most encouraging.     

Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy

BACKGROUND: Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS: Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS: No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS: Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.     

Spontaneous dissection of coronary artery in a patient with ascending aortic aneurysm and aortic valve regurgitation.

Spontaneous coronary artery dissection is a rare cause of myocardial infarction associated with a significant high morbidity and mortality. It usually occurs in relatively young patients and it is frequently found at autopsy. We report a case of a 42-year-old woman, who underwent resection of subaortic diaphragm ten years earlier presenting with postero-lateral myocardial infarction. Coronary arteriography revealed a dissection of the left main stem extending distally to the left anterior descending artery (LAD) and circumflex artery (Cx); occlusion of the postero-lateral branch of the Cx; severe aortic valve regurgitation and ascending aortic aneurysm. She was successfully operated on in emergency and underwent myocardial revascularization and separate replacement of the aortic valve and the ascending aorta. In this specific case of coronary dissection and severe aortic regurgitation it is mandatory to perform surgery in emergency to limit infarction evolution and avert loss of life.     

Surgical treatment and their long-term results of the ascending aortic lesions involving coronary arteries

Seventeen patients underwent surgical treatment of the ascending aorta, aortic valve, and coronary artery as well. Diagnosis of 13 patients were annulo-aortic ectasia, 3 had dissecting aneurysm (type I: 2, type II: 1), and one had supra-valvular aortic stenosis. In annulo-aortic ectasia, Bentall's method was carried out in 11 cases, and Cabrol's operation was performed in 3, one of the latter group had received Bentall's procedure 4 years prior to the second operation. One patient died of acute myocardial infarction 3 days following operation, who had severe stenosis of the left anterior descending artery not detected by preoperative angiography. During long-term follow up, 2 patients died of cardiac failure. Three patients had dissection of the ascending aorta and coronary artery (right coronary artery: 2, left coronary artery: 1). The aorta was reconstructed, aortic valve was replaced, and coronary artery was revascularized with saphenous vein graft. They have been alive and well up to post operative 6 years. Right coronary ostioplasty as well as aortic valve replacement and extended aortoplasty were attempted in one patient with Williams' syndrome. This patient had been well until sudden death which occured 11 months after the operation.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

Rupture of a chronic dissecting giant aneurysm into the pulmonary artery; report of a case

Aortopulmonary fistula is an extremely rare complication of aortic dissection. We report a case of a chronic dissecting giant aneurysm with an aortopulmonary fistula. A 78-year-old woman experienced sudden onset chest pain and oppression. Chest X-ray showed ascending aortic and left ventricular enlargement and pulmonary congestion. Computed tomography (CT) confirmed the 100 mm ascending aortic aneurysm with dissection and aortopulmonary fistula. Operative repair was performed under profound hypothermic circulatory arrest with selective cerebral perfusion. The proximal and distal end were obliterated using a gelatin-resorcin-formaldehyde tissue glue and reinforced with a Teflon felt circumferential strip. The ascending aorta was replaced by a 30 mm coated Dacron vascular graft and the aortopulmonary fistula was closed with pledgeted vertical mattress suture. Postoperative CT showed a normally functioning vascular implant without any sign of aortopulmonary shunt or pulmonary artery stenosis.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Extended repair of thoracic aorta through left thoracotomy after aortic root replacement

A patent distal false lumen after repair of type A aortic dissection often poses serious late complications. We present a successful repair of dissecting aortic aneurysm through left thoracotomy, extending from the ascending to descending thoracic aorta after composite graft replacement of the aortic root. Although staged operations, including the elephant trunk procedure, are usually chosen for remaining extensive aortic disease after replacement of the aortic root or the ascending aorta, a single-stage repair from the ascending to the descending thoracic aortas through left thoracotomy can be a favorable option to treat a patient with this type of aortic disease.     

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.     

Surgical case of aortic root and thoracic aortic aneurysm after the Wheat procedure.

A 52 year-old man underwent aortic valve replacement and ascending aortic replacement (Wheat procedure) for acute dissection (Stanford type A) and aortic regurgitation (grade 3/4). At that time, the aortic root was slightly dilated at about 45 mm and the descending aorta was within a normal range at about 35 mm. Forty months after the initial operation, a follow-up chest enhanced computed tomography showed an aortic root aneurysm about 60 mm in diameter, a thoracic aortic aneurysm about 70 mm in diameter and chronic aortic dissection. First we performed the Bentall procedure, innominate artery and left common carotid artery replacement by 12 mm, and 10 mm Hemashield grafts during selective cerebral perfusion. After 10 weeks, we carried out aortic arch, descending aorta and left subclavian artery replacement. The postoperative course was uneventful and postoperative examination demonstrated a good surgical result. Histological findings of the aortic aneurysm wall showed cystic medial necrosis, but Marfan's syndrome was excluded clinically. We could diagnose aortic root aneurysm by regular follow-up chest enhanced computed tomography (CT) and echocardiography. Therefore, cases with slight dilation of the aortic root in the Wheat procedure should undergo regular follow-up evaluation by chest enhanced CT and echocardiography.     

Use of profound hypothermia and circulatory arrest in complex intra-cardiac repair in adults

Profound hypothermia and circulatory arrest is a well worked out technique for total repair of congenital defects in infants. Recently, it has been popularized for the repair of aneurysms of the transverse aortic arch. We have applied this technique of profound hypothermia and circulatory arrest in three other adult patients in whom conventional techniques would not allow safe and adequate complete repair of acquired intra-cardiac defects. The first patient, a 76-year-old female, had a large chronic ascending aortic aneurysm involving the aortic valve, as well as the innominate and left common carotid arteries. Resuspension of the aortic valve, resection of the ascending aneurysm, and reconstruction of the ascending and transverse aorta were performed under profound circulatory arrest. In addition, multi-dose hypothermic blood K+ cardioplegia was utilized to protect the myocardium. The second patient underwent valve replacement during a period of circulatory arrest because of extensive calcification of the entire ascending aorta and transverse aortic arch. Arrest time was 56 minutes. The third patient was a 54-year-old female and had a large patent ductus arteriosus with a 3:1 left-to-right shunt as well as significant aortic and mitral valve disease. The ductus was closed through an incision in the pulmonary artery during a 13-minute period of profound hypothermia and circulatory arrest. Aortic valve replacement and mitral repair were also performed at the same time, utilizing conventional techniques. All three patients recovered uneventfully with no evidence of any significant neurologic defect. Long-term follow-up has shown improvement in functional classification in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endarterectomy and graft replacement of severely calcified (porcelain) ascending aorta with coronary ostial involvement in a patient requiring aortic valve replacement.

We report a successful aortic valve replacement within an extensively calcified (porcelain) aorta, involving the left coronary artery ostium. Clamping such an aorta can result in embolization, dissection, and mural laceration. A 72-year-old female presented with a severely calcified and stenotic aortic valve with a peak pressure gradient of 101 mmHg. Computed tomography demonstrated extensive calcification of the ascending aorta. Coronary angiogram showed a 50% ostial left coronary artery stenosis. Under deep hypothermic circulatory arrest, the aorta was transected at the proximal arch and distal graft anastomosis was performed. This was followed by endarterectomy of the porcelain ascending aorta and the left coronary ostium. Aortic valve replacement, proximal aortic graft anastomosis, and a coronary artery bypass grafting (CABG) with the left internal thoracic artery (LITA) anastomosed to the left anterior descending artery (LAD) were then performed in a sequential manner.     

Surgery of the descending thoracic aorta: spinal cord protection with the Gott shunt

From July, 1974, to July, 1987, surgical treatment of descending thoracic aortic aneurysms was performed in 173 patients at l'H?pital du Sacré-Coeur de Montréal. The cause of the aneurysms was arteriosclerosis or medial degeneration in 83 patients, trauma in 50, dissection in 34, and a congenital malformation in 6. A single method of external shunting provided distal perfusion in all patients in the series. A 9-mm Gott aneurysm shunt was placed preferentially between the ascending aorta (67%) and the descending aorta (60%). Alternative sites of proximal cannulation (aortic arch, 9%; proximal descending aorta, 22%; left ventricle, 2%) and distal cannulation (abdominal aorta, 3%; left femoral artery, 37%) were chosen based on the location and the extent of the aortic aneurysm. No systemic heparinization was used. In the last 40 patients, a flowmeter adapted for use with the shunt allowed the recording of shunt flow (mean, 2,475 ml/min; range, 1,100 to 4,000 ml/min). Hospital mortality, including patients with ruptured aneurysms, was 15% (26/173). The mean aortic cross-clamp time was 37 minutes (range, 8 to 105 minutes). Of the 173 patients, 168 survived long enough to allow accurate clinical evaluation of the function of the spinal cord: no paraplegia or other spinal cord ischemic injury occurred. To date, our clinical experience has demonstrated the effectiveness of the 9-mm Gott shunt in preserving the functional integrity of the spinal cord during cross-clamping of the thoracic aorta.     

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.     

Single-stage reoperative repair of chronic type A aortic dissection using the arch-first technique

BACKGROUND: Management of the enlarged, chronically dissected aorta after previous repair of acute ascending aortic dissection or after a previous cardiac operation may present a formidable technical challenge and the optimal method of management is not clearly established. METHODS: Twenty-one patients with chronic type A aortic dissection (mean age 57 years) underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending thoracic aorta. Single-stage replacement with perfusion of the aortic arch first to minimize the duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision were used. Fourteen patients had undergone previous repair of acute type A dissection. Seven patients had type A dissection after aortic valve replacement (3 patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta distal to the left subclavian artery precluded a two-stage repair. The mean interval between the initial and reoperative procedures was 69 months (range, 5 to 249). RESULTS: There was 1 (4.8%) hospital death. Four patients required reoperation for bleeding. One patient required a right ventricular assist device that was successfully removed. Ten patients required assisted ventilation for more than 48 hours. All were successfully weaned from ventilatory support. No patient had a stroke or other adverse neurologic outcome. There has been 1 late death (mean follow-up 2 years). CONCLUSIONS: The single-stage, arch-first replacement technique is a safe and effective procedure for patients who require extensive reoperations for chronic expanding type A dissection.     

Acute dissection of the descending thoracic aorta: repair in an unusual case

Acute tamponade, although a rare manifestation of a descending thoracic aneurysm, was the dominant clinical feature of a classic type III dissecting aneurysm (arising distal to the left subclavian artery) in a 52-year-old man. High-quality aortography confirmed the diagnosis, ruling out any anomaly of the ascending aorta and the aortic arch. Surgical treatment was carried out 24 hours after the initial episode without cardiopulmonary bypass. Through a left thoracotomy, a Gott shunt was inserted proximally at the apex of the left ventricle and distally in the left femoral artery. Aortic repair with the interposition of a 30-mm woven Dacron prosthesis was successful. Postoperative aortography showed complete restoration of aortic integrity.