A practical tool to control bleeding during sternal reentry for pseudoaneurysm of the ascending aorta

Big pseudoaneurysms of the ascending aorta after a previous thoracic operation are rare and represent a surgical challenge. Because the rupture during sternal reentry occurs before the clamp-control of the distal ascending aorta, it is essential to control the bleeding until the adhesions are released in order to place the sternal retractor. We report the use of Foley catheter with a malleable guidewire to control the bleeding from the defect in the ascending aorta causing a pseudoaneurysm in case of a limited access.     

Spontaneous Rupture of a Nonaneurismatic Ascending Thoracic Aorta

Abstract   Spontaneous rupture of the ascending thoracic aorta without any history of aneurysm, trauma, infection, dissection, or previous surgery is a very rare and potentially lethal event. We report a case of spontaneous rupture of the ascending aorta treated successfully. While the etiology is still unclear, diagnosis with bedside transesophageal echocardiography prompted emergent surgical intervention.     

Spontaneous rupture of the right sinus of valsalva mimicking an ascending aortic intramural hematoma

Spontaneous ruptures of the ascending aorta are extremely rare and require emergent surgical intervention. We report a case of a delayed diagnosis of a spontaneous, localized periostial rupture of a nondilated right sinus of Valsalva, which mimicked an intramural hematoma of the ascending aorta. The diagnosis and surgical management of this unusual pathology is the subject of this case report.     

An aneurysm at the cannulation site discovered 40 years after cardiac surgery: report of a case

We report the successful surgical treatment of a pseudoaneurysm of the ascending aorta in a 45-year-old man who underwent surgical closure of a ventricular septal defect at the age of 5. A computed tomography scan ordered for the investigation of a pulmonary mass happened to detect a pseudoaneurysm (20 mm diameter). The pseudoaneurysm protruded anteriorly from the ascending aorta at the previous aortic cannulation site. The ascending aorta, including the lesion, was replaced with a prosthetic graft uneventfully. The cause of the pseudoaneurysm was considered iatrogenic, since he had no prior history of postoperative mediastinitis or blunt chest trauma. A computed tomography scan is a useful means to detect a mass on the ascending aorta following cardiac surgery, and it provides important information to help define a surgical strategy.     

Off-Pump Extraanatomic Bypass from the Ascending to the Descending Aorta for Re-Operation of Interrupted Aortic Arch in an Adolescent

Abstract   The appearance of re-stenosis after repair of an interrupted aortic arch may be a surgical challenge due to adhesions. Here, we describe an approach using off-pump coronary artery bypass grafting techniques to reach the descending aorta through a median sternotomy in a patient with aortic arch stenosis after conduit repair. The 17-year-old patient with diagnoses of interrupted aortic arch and ventricular septal defect presented after two previous operations (one left lateral thoracotomy and one median sternotomy) with a stenosed vascular graft between ascending and descending aorta. Surgery was done via re-sternotomy without cardio-pulmonary bypass. An extraanatomic graft was used to connect ascending and descending aorta. When performing the distal anastomosis, the heart was exposed using a standard suction device. This case demonstrates that the use of modern techniques may facilitate surgical approaches dramatically. In our opinion the above-described technique is the first choice for all patients requiring arch repair following multiple previous operations, performed via sternotomy and thoracotomy.     

Impending rupture of the ascending aorta due to giant cell arteritis

Giant cell arteritis may occasionally lead to vessel perforation without previous dissection. At the level of the ascending aorta, however, such an event has been reported only three times. We report a fourth case of impending rupture of the ascending aorta due to a small and isolated lesion of giant cell arteritis. In contrast to previous reports, laboratory and clinical manifestations suggestive of giant cell arteritis were absent in this case so that the diagnosis could only be established on histologic examination of the operative specimen.     

Arterial-level repair of transposition of great arteries without coronary artery transfer

Hypoplastic ascending aorta and interrupted aortic arch (IAA) are rarely associated with dextro-transposition of the great arteries (D-TGA). Severe hypoplastic ascending aorta may preclude coronary artery transfer making arterial switch operation problematic. We report a case of D-TGA with a large subpulmonic ventricular septal defect, IAA, and hypoplastic ascending aorta that underwent successful biventricular surgical repair without coronary artery transfer.     

Acquired supravalvular aortic stenosis: a late complication of replacement of the ascending aorta.

Aortic syndromes are an increasing cause of morbidity and mortality. Ascending aortic dissection is a clinical emergency with most patients requiring open surgery to replace the ascending aorta. Detection through clinical suspicion, improved non-invasive imaging and refined surgical techniques have resulted in an improved survival rate. Acquired supravalvular aortic stenosis is an extremely rare complication of cardiac surgery. We present the case of a patient who, 15 years after undergoing elective replacement of the ascending aorta for aortic dissection, required repeat surgery for symptomatic supravalvular aortic stenosis. This case elegantly highlights the need for a detailed focused assessment in patients where the clinical presentation does not correlate with initial investigations. To our knowledge this is the first reported case of late symptomatic supravalvular aortic stenosis following replacement of the ascending aorta.     

Circumferential rupture of the ascending aorta in a fusiform aneurysm.

A case of complete circumferential rupture of the ascending aorta with massive hemorrhage into the pericardial space and around the aortic arch is described. Computed tomography was used to establish the diagnosis. Rupture occurred distal to the origin of the coronary arteries without impairment of aortic valve function, and therefore a preclotted woven Dacron graft was inserted. To the best of our knowledge, this is the first documented case of complete rupture of the ascending aorta in a fusiform aneurysm and the first report of its successful surgical treatment.     

Rare diagnosis of fibrous cardiac diverticulum in an adult followed by urgent surgical intervention

We describe the case of a 59-year old male patient with an acute onset of chest pain who was admitted to our unit with a suspected rupture of the left ventricle pseudoaneurysm, compressing the left atrium and the ascending aorta. Our urgent surgical intervention caused us to reject our initial diagnosis and revealed a cardiac diverticulum arising from the left ventricle outflow tract, spreading to the sub-valvular area compressing the left atrium, the ascending aorta and the pulmonary trunk, and compromising the aortic and mitral valve, causing moderate regurgitation. We removed the defect and replaced the aortic valve, eliminating the compression of the left atrium, aorta and pulmonary trunk. This article discusses the surgical technique for treating this ventricular diverticulum, its aetiology and the possible differential diagnosis in this case.     

Successful treatment for intraoperatively evolving acute aortic dissection in a neonate

Acute aortic dissection is a life-threatening condition. We report the case of a neonatal one-stage correction of coarctation and hypoplastic aortic arch repair plus ventricular septal defect closure. While dissecting the head vessels after cannulation of the ascending aorta and commencing cardiopulmonary bypass, type A aortic dissection evolved. This required immediate ascending aorta and aortic arch reconstruction with coarctation of the aorta resection under hypothermic circulatory arrest. The surgical management of this rather unique situation is discussed here.     

Rupture of ascending aorta secondary to tuberculous aortitis

Tuberculous aortitis generally develops at the distal aortic arch and the descending aorta that are close to specific groups of mediastinal lymph nodes, but exceptionally it develops in the ascending aorta. We report a case of rupture of the ascending aorta after tuberculous aortitis in a 53-year-old man without a history of tuberculosis or evidence of a primary foci who underwent cardiopulmonary resuscitation due to severe hemoptysis with subsequent cardiac arrest. The tuberculous aortitis associated with rupture of the ascending aorta was treated with surgical resection and in situ graft placement.     

Combined Surgical Treatment in Aortic Type A Dissection

Abstract   Acute Stanford type A aortic dissection is a fatal event that, for its high mortality when left untreated, requires urgent surgical intervention. The established treatment includes repair of the ascending aorta and various portions of the aortic arch, leaving the descending aorta untreated. We report the case of a 62-year-old man in whom a combined approach of the ascending aorta with surgical correction and transluminal placement of a stent in the aortic arch was performed.     

Dissection of the Ascending Aorta: A Late Complication of Coronary Artery Bypass Grafting

Acute dissection of the ascending aorta as a late complication of coronary artery bypass grafting has been rarely reported. We report a case of a 61 year-old man in whom acute dissection of the ascending aorta developed 2 years after coronary artery bypass grafting. The ascending aorta was replaced with a Dacron graft, and an island of the aortic wall, on which previous proximal anastomoses had been placed, was implanted into the Dacron graft successfully.     

Surgical treatment of Stanford type A acute aortic dissection with stenosis of the branches of aortic arch: report of two cases

Recently two cases of Stanford type A acute aortic dissection with stenosis of the branches of aortic arch were operated. Both of them had the intimal tear in the ascending aorta, and the stenosis caused by the dissection was present in the left subclavian artery in the first case and in the brachiocephalic and the right common carotid arteries in the second case. Repairs of the dissected ascending aorta were performed successfully with the interposition of the ringed intraluminal graft in the first case, and with the composite graft replacement of the ascending aorta and the aortic valve in the second case. Complete remission or significant relief of the branch stenoses which had not been given direct surgical repairs was observed by the postoperative angiograms.     

Punch-hole aneurysm of the ascending aorta after coronary artery bypass surgery

This report describes the case of a 60-year-old man, who developed a giant punch-hole aneurysm of the ascending aorta five month after uncomplicated coronary artery bypass grafting (CABG) due to a localized rupture of the ascending aorta. The patient underwent surgical repair with cardiopulmonary bypass. Because the false aneurysm was adherent to the sternum, resternotomy was performed in deep hypothermia and circulatory arrest. The lesion in the ascending aorta was closed by means of a dacron-patch. The postoperative course of the patient was completely uneventful. We recommend to repair a false aneurysm of the ascending aorta in deep hypothermic circulatory arrest (DHCA) in order to avoid excessive blood loss during sternotomy.     

Fortschritte in der Behandlung thorakaler Aortenaneurysmen

Surgical treatment of combined pathologies of the ascending aorta, aortic arch and the descending aorta still makes great demands on the surgeon. In 1983 Borst et al. established the elephant trunk procedure for treatment of such complex aortic aneurysms, which subsequently became the recognized standard procedure and has simplified the surgical treatment of these pathologies. The frozen elephant trunk technique (hybrid procedure) was recently introduced as an extension of this procedure. This procedure permits the single-stage definitive treatment of intersegmental aneurysms extending over the ascending aorta, the aortic arch and the descending aorta via transmediastinal sternotomy using a new type of prosthetic bypass graft with stent portion, which is inserted anterograde in the descending aorta. The aortic arch and, if necessary, the ascending aorta are subsequently replaced in the conventional manner. The new procedure can be implemented with a risk probability which is comparable to that of the elephant trunk technique. The main advantage is that this is a single-stage approach and the second stage which is necessary by the conventional approach can be omitted. Although the surgical strategy is oriented to the individual pathology of each patient, the frozen elephant trunk technique could replace the previous conventional procedure as the treatment standard for extensive aortic aneurysms.     

Recurrent rupture of a mycotic ascending aortic aneurysm: a surgical and medical challenge.

Infection in the vascular tree remains one of the greatest challenges for vascular surgeons. Despite technical advances and newer antibiotics, the morbidity and mortality remain high. The following case report underlines the complex factors encountered in a 62-year-old alcoholic patient presenting with a "classical" history of mycotic aneurysmal disease who suffered from recurrent rupture of the aneurysm of the ascending aorta. In situ reconstruction of the ascending aorta was performed with patch of xenopericardium. As demonstrated in this case, aggressive surgical management and long-term triple antibiotic therapy can salvage patients even with multiple complications in the early postoperative period.     

Aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and aneurysm of the ascending aorta. Report of a case with successful surgical repair.

A case of aneurysm of the main stem of the left coronary artery associated with aortic insufficiency and an aneurysm of the ascending aorta is reported. The importance of coronary angiography in diagnosing this condition is illustrated. Surgical repair included isolation of the coronary aneurysm and replacement of the ascending aorta and aortic valve, combined with triple aortocoronary saphenous vein bypass grafts. A review of the aetiology, clinical features, and surgical management of coronary artery aneurysms is presented.     

Apicoaortic valved conduit is a good alternative for aortic stenosis with porcelain aorta after off-pump coronary artery bypass grafting

We report a case of aortic stenosis with porcelain aorta using an apicoaortic valved conduit after 'aortic no touch' off-pump coronary artery bypass grafting. Apicoaortic valved conduit is a good surgical option for this patient to avoid re-entry through the sternum, injury to patent graft and manipulation of the porcelain ascending aorta.