Chronic traumatic aneurysms of the descending thoracic aorta

Between 1970 and December 1984, 28 patients with post-traumatic chronic aneurysm of the descending thoracic aorta were consecutively operated on in our Division of Cardiac Surgery. Ages ranged from 16 to 66 years (mean 38 years); 25 were male and three were female. In all cases, a history of a major deceleration injury was documented. The interval between trauma and operation ranged from 2 to 50 years (mean 11.4 +/- 7.8). Twenty-three (82.1%) were asymptomatic. Only one operation was performed on an urgent basis for recurrent episodes of hemoptysis. All patients underwent resection with prosthetic tubulargraft (25 cases) and patch-graft (3 cases) replacements. In all patients but one, left heart bypass was employed. No hospital deaths, late deaths, paraplegia or graft-related complications occurred. Considering the risk of late rupture and the young age of most of the patients, surgery in chronic post-traumatic aneurysms of the descending thoracic aorta is always indicated. We consider left heart bypass a safe technique in preventing renal and medullar ischemic injuries.     

Surgical treatment of multiple mycotic aneurysms: in the ascending aorta,aortic arch,and descending aorta

We report a clinical case of multiple mycotic aneurysms, in the ascending aorta, aortic arch, and descending aorta. The patient underwent surgery to replace the ascending aorta and aortic arch by means of a highly modified "elephant trunk" technique and with the aid of arterial cannulation from the right subclavian artery, which provided antegrade cerebral perfusion. Samples of purulent material taken from the aneurysmal wall yielded cultures positive for Staphylococcus aureus. The patient was treated with antibiotics for 6 weeks and then underwent a 2nd procedure for the aneurysmal resection of the descending thoracic aorta and the abdominal aorta, through a thoracic laparo-phrenicectomy. We comment on the clinical and surgical aspects of the case.     

Endovascular repair of lesions of descending thoracic aorta: aneurysms and dissections

The morbidity and mortality of open repair of descending thoracic aortic lesions remains uncomfortably high. Shortly after the advent of an endovascular approach for infrarenal abdominal aortic aneurysms, attempts have been made to apply similar technologies to the thoracic aorta. Early experiences with endovascular grafts for thoracic aortic aneurysms have met with good to moderate success but have provided a framework for development of improved technologies specifically designed for this anatomic region. Early studies with second generation devices have shown more promise. Aortic dissections, a disease state associated with an exceptionally high morbidity and mortality, represent another condition that is readily treated with an endovascular approach.     

Clinical experience with PTFE graft replacement in the descending thoracic aorta

In 6 cases, we have performed polytetrafluoroethylene (PTFE) graft replacement in the descending thoracic aorta, with all patients alive and showing good results. Fifty months have passed since the first graft replacement, but no complications due to the PTFE graft have occurred.     

Evolution of the treatment of chronic post-traumatic aneurysms of the descending thoracic aorta: 30 years experience

The authors present the early and late results of a series of 40 patients treated for chronic post-traumatic aneurysms of the descending thoracic aorta from 1975 to 2005. With the exception of a patient who died of an intra-pleural rupture before surgery, the patients were treated by aortotomy and prosthetic graft (N=17), aortotomy and direct suture (N=17) or endoprosthesis (N=5). The use of distal aortic perfusion in 22 patients enabled 17 direct sutures (77.3%) thanks to extensive mobilisation of the aortic arch. Endoprostheses have been used since 1997 in high surgical risk patients with severe comorbid conditions. There were no deaths, one transient paraparesia after simple aortic clamping, one reoperation for a haemothorax and four cases of dysphonia due to paralysis of the recurrent laryngeal nerve. Thirty-five patients (90%) were followed up for an average of 119.7 +/- 16.4 months. There were no clinical complications and the late morphological results were good in all cases with the exception of one type 1 endoprosthetic leak. The treatment of chronic post-traumatic aneurysms of the descending thoracic aorta gives excellent early and late results, justifying wide operative indications. The wish to avoid use of a prosthesis in young patients with a long life expectancy should give preference to conventional surgical techniques which, providing distal aortic perfusion is employed, allow direct suture of three quarters of cases. Endovascular treatment is reserved only for "poor surgical risks".     

Surgical treatment of aneurysms of the abdominal and thoracic aorta

The danger of an arteriosclerotic abdominal aortic aneurysm is clearly related to the size of the aneurysm. From available clinical data it seems logical to recommend elective surgical excision and graft replacement of abdominal aneurysms 6 cm or greater in diameter because of the considerable danger of rupture of untreated aneurysms of this size. Although small aortic aneurysms do rupture, most patients with small abdominal aneurysms may be safely followed with examination at regular intervals. Surgery is reserved for those who demonstrate evidence of aneurysm expansion. The operative mortality rate for elective surgical excision of abdominal aortic aneurysms is by no means negligible but has probably diminished recently to levels of approximately 5% in the hands of experienced surgeons. Achievement of an operative mortality rate in this range requires sensible case selection, expeditious operative management and skillful postoperative care with particular attention to problems of hypoxemia in the early postoperative period.Patients with ruptured abdominal aortic aneurysms require immediate aneurysm resection for survival. Of those patients with ruptured abdominal aneurysms who reach the hospital alive, approximately 60% should be salvaged at present by emergency surgery.The prognosis of the patient with a thoracic aortic aneurysm depends upon the etiology of the aneurysm. Syphilitic aneurysms of the thoracic aorta are now fortunately rare but appear to have a high incidence of rupture. The prognosis of patients with arteriosclerotic aneurysms, which characteristically involve the descending thoracic aorta, appears to be considerably better than that of patients with aneurysms of the abdominal aorta for unknown reasons. Since the removal of thoracic aneurysms ordinarily requires extracorporeal bypass and is associated with an operative mortality rate in the range of 20%, considerable judgment must be exercised in case selection for elective resection of such aneurysms.The surgery of dissecting aneurysms of the thoracic aorta has recently been modified by the widespread acceptance of antihypertensive drug therapy for acute dissection. Surgery may be reserved, hopefully on an elective basis, for those patients with significant aortic valvular insufficiency, significant aneurysmal dilatation of the dissected aorta, or symptomatic involvement of a major aortic branch in the dissection.     

Temporary extraanatomic subclavian-to-femoral bypass. An auxiliary method in the treatment of aneurysms of the descending thoracic aorta

A new technique to perfuse the lower half of the body during clamping of the thoracic aorta is described. Viability of the visceral organs and the spinal cord is maintained using an extraanatomical 10 mm graft inserted between the right subclavian and the left common femoral arteries. The results in 21 cases are analysed. No hypoxic organ damage was encountered. This simple technique probably adds to the safety of the patient undergoing surgery on the descending aorta.     

Endovascular repair for thoracic aortic arch aneurysms.

AIM: The aim of this study was to report our experience with total and subtotal endovascular stent-grafting combined with aortic arch branch surgical revascularization for thoracic aortic arch aneurysms in high-risk patients. METHODS: From December 2000 to June 2005, among 38 patients treated with thoracic stent-grafts in our department, 10 patients (9 men; mean age 71+/-6 years) at high risk for open repair were candidates for endovascular repair and/or aortic arch branch extra-anatomical reconstruction due to inadequate proximal landing zones. The left subclavian artery was over-stented 6 cases for zone 2 aneurysms, and partial or total arch stent-grafting with simultaneous revascularization of the arch branches was performed in 4 cases for zones 0-1 aneurysms. RESULTS: Primary technical success rate was 100%. In-hospital mortality rate was 10%. Neither paraplegia, nor acute renal failure were recorded. Immediate or late surgical conversion was never required. One type 1b was successfully treated with additional stent-graft and 2 type-2 endoleaks were sealed by coil embolization. Mean follow-up was 21-months (range 3-48 months); overall, survival rate at 12, 26, and 36 months was 90%, 60%, and 30%, respectively. CONCLUSIONS: Endovascular repair for thoracic aortic arch aneurysms is feasible. However, our experience suggests stent-grafting is not free of risk, and long-term and larger follow-up is required.     

Endovascular treatment of the malignant thrombus in the descending thoracic aorta

Thrombus in the Non-aneurysmal, Non-atherosclerotic Descending Thoracic Aorta (NAADTA) represents a rare source of peripheral arterial embolism. Despite being mostly asymptomatic process, its consequences can be very serious. In this case report, we described the case of a patient with malignant thrombus occurring in otherwise “healthy” descending thoracic aorta, already complicated by embolization into superior mesenteric artery, subsequently solved by stent graft implantation into the thoracic aorta.     

Functional chiral asymmetry in descending thoracic aorta

To determine whether rotational blood flow or chiral asymmetry exists in the human descending thoracic aorta, we established the ability of color Doppler ultrasound to detect rotational flow in a tornado tube model of a vortex descending fluid column. In a model of the human aortic arch with a pulse duplicator, color Doppler was then used to demonstrate that rotational flow occurs first in the transverse arch and then in the proximal descending thoracic aorta. With the use of color Doppler esophageal echocardiography, 53 patients (age range, 25-78 years; mean age, 56.4 years) were prospectively examined for rotational flow in the descending thoracic aorta. At 10 cm superior to retro-left ventricular position, 22 of 38 patients (58%) revealed rotational flow with obvious diastolic counterclockwise rotation but less obvious systolic clockwise rotation. At 5 cm superior to retro-left ventricular position, 29 of 46 patients (63%) revealed rotational flow with a tendency toward systolic clockwise and diastolic counterclockwise rotation. At the retro-left ventricular position, 47 of 53 patients (89%) revealed rotational flow, usually of a clockwise direction, occurring in systole. Our data suggest that aortic flow is not purely pulsatile and axial but has a rotational component. Rotational flow begins in the aortic arch and is carried through to the descending thoracic aorta, where flow is chirally asymmetric with systolic clockwise and diastolic counterclockwise components. These data demonstrate an aortic rotational flow component that may have physiological implications for organ perfusion.     

Ascending aorta-supraceliac abdominal aorta bypass: successful removal of an infected graft in the descending thoracic aorta.

An infected graft and a mycotic pseudoaneurysm were successfully resected by employing an ascending aortasupraceliac abdominal aorta bypass graft in a 19-year-old man. He had formerly undergone graft replacement surgery for traumatic aneurysm of the descending thoracic aorta, with the aid of a temporary external bypass graft. After this first operation, the patient had suffered from septicemia due to Psudomonas aeruginosa, which resulted in formation of mycotic pseudoaneurysms at the distal anastomotic site of the prosthetic graft and at both stumps of the formerly employed external bypass graft.     

Tuberculous pseudo-aneurysm of the descending thoracic aorta

A tuberculous pseudo-aneurysm of the thoracic descending aorta was found in a 57 year-old female with haemoptysis three months after successful chemotherapy for a miliary tuberculosis. After aortic angiography, the aneurysm was resected and the aorta was repaired with a Dacron prosthetic graft. The patient is doing well one year after the operation.     

Tuberculous aneurysms of the descending thoracic aorta: report of a case with fatal rupture.

Tuberculous aortic aneurysm is a rare disease entity. The majority of affected patients succumb to perforation and exsanguination. The only chance for survival and cure is by resection and prolonged antituberculosis chemotherapy. Our case illustrates the high risk of rupture of tuberculous aortic aneurysms. Post-mortem examination revealed that the mechanism of aneurysm formation was by direct caseous involvement of the descending thoracic aorta from a juxtaposed left upper lobe parenchymal tuberculous process. Our findings also favor the concept that miliary dissemination (in the presence of tuberculous aortic aneurysm) is the result rather than the cause of the tuberculous aortic process.     

Transesophageal magnetic resonance imaging of the aortic arch and descending thoracic aorta in patients with aortic atherosclerosis

OBJECTIVES

We sought to determine the feasibility and potential of transesophageal magnetic resonance imaging (TEMRI) for quantifying atherosclerotic plaque burden in the aortic arch and descending thoracic aorta in comparison with transesophageal echocardiography (TEE).

BACKGROUND

Improved morphologic assessment of atherosclerotic plaque features in vivo is of interest because of the potential for improved understanding of the pathophysiology of plaque vulnerability to rupture and progression to clinical events. Magnetic resonance imaging (MRI) is well suited for atherosclerotic plaque imaging. Performing MRI using a radio frequency (RF) receiver probe placed near the region of interest improves the signal-to-noise ratio (SNR).

METHODS

High-resolution images of the thoracic aortic wall were obtained by TEMRI in 22 subjects (8 normals, 14 with aortic atherosclerosis). In nine subjects, we compared aortic wall thickness and circumferential extent of atherosclerotic plaque measured by TEMRI versus TEE using a Bland-Altman analysis. Additional studies were performed in a human cadaver with pathology as an independent gold standard for assessment of atherosclerosis.

RESULTS

In clinical and experimental studies, we found similar measurements for aortic plaque thickness but a relative underestimation of circumferential extent of atherosclerosis by TEE (p = 0.001), due in large part to the lower SNR in the near field.

CONCLUSIONS

Using TEMRI allows for quantitative assessment of thoracic aortic atherosclerotic plaque burden. This technique provides good SNR in the near field, which makes it a promising approach for detailed characterization of aortic plaque burden.     

Experimental and clinical use of somatosensory evoked potentials in surgery of aneurysms of the descending thoracic aorta

The use of somatosensory evoked potentials (SEP) for the detection of spinal cord ischemia in surgery of the descending thoracic aorta was studied in nine dogs. Also 18 patients (group A) operated upon without distal aortic perfusion and 10 patients (group B) operated upon with distal aortic perfusion were studied. Tibial nerve stimulated SEP was used. Crude SEP characteristics and the reliability of SEP were assessed. In dogs the preservation of SEP corresponded with absence of neurological damage (p less than 0.02). Loss of SEP and late or absent recovery were associated with presence of neurological damage histopathologically proved (p less than 0.05). In group A SEP recording was affected by peripheral ischemia whereas this phenomenon was absent in group B during perfusion. In group A no relation was observed between the preservation, loss, and recovery of signal and the presence of neurological damage. In group B loss and recovery of SEP corresponded with assumed reperfusion of the spinal cord. Additional SEP recording obtained from stimulation of the skin overlying the fourth lumbar vertebra and of the medullary conus were preserved over a longer period. In patients this type of SEP was especially useful and reliable in case distal aortic perfusion was not used.