A case of acute A type aortic dissection with lower extremity ischemia--percutaneous fenestration of the aortic septum followed by ascending aortic graft replacement by open distal anastomosis and retrograde cerebral perfusion]

A 56-year-old woman with severe back pain and a cold, pulseless right extremity was admitted to our hospital. Angiogram revealed a type A aortic dissection extending from ascending aorta to the aortic bifurcation with no definite re-entry point. The false lumen gave origin to the right renal artery and the right external iliac artery was occluded. Therefore, a catheter was manipulated into the true lumen through a percutaneous right femoral artery approach, and was advanced into the false lumen through the right posterolateral wall of the dissecting aortic septum. Fenestration was then performed with fully dilated angioplasty balloon across the septum. Immediately after the procedure, the patient's symptoms improved. The day after the fenestration, replacement of the ascending aorta with 24 mm woven Dacron graft was followed under the deep hypothermia and the retrograde cerebral perfusion. The patient followed a satisfactory postoperative course and postoperative angiogram showed a complete closure of the entry at the ascending aorta and adequate revascularization of the right renal and external iliac arteries.     

Femoral artery perfusion for cardiopulmonary bypass in patients with aortoiliac artery obstruction

A patient with type I aortic dissection, ascending aortic aneurysm, and infrarenal aortic occlusion was managed by inserting an infrarenal bifurcation graft and using one limb as arterial access for cardiopulmonary bypass. Following ascending aorta and aortic arch repair, the aorto-bi-common femoral artery bypass was completed. In patients with severe aortoiliac occlusive disease, graft replacement can provide access for both cardiopulmonary bypass and intraaortic balloon pump insertion.     

Technical strategy for the endovascular management of ascending aortic pseudoaneurysm

We present two cases of ascending aortic pseudoaneurysm exclusion with off-the-shelf aortic stent grafts. The right common carotid artery was used for access to facilitate graft delivery. Control of graft deployment was aided using a compliant right atrial occlusion balloon to lower cardiac output at the time of deployment. Transesophageal echocardiography facilitated the sizing and positioning of the right atrial balloon and was used to survey the heart and ascending aorta on successful exclusion of the pseudoaneurysm. These simple maneuvers made an uncommon procedure straight forward, predictable, and successful.     

Hemiarch replacement during pregnancy (19 weeks) utilizing normothermic selective cerebral perfusion

A 20-year-old woman with Marfan syndrome in the 19 weeks of pregnancy was admitted for a dissecting aneurysm of the ascending aorta to the proximal arch. She wanted to continue with pregnancy. A cardiotocography and a trans-esophageal echo probe which allowed visualization of the fetal heart contraction were attached on the abdomen. A cardio-pulmonary bypass was established via the right axillar and femoral arteries with bicaval drainage. The aortic isthmus and arch branches were clamped. After opening the ascending aorta, selective cerebral perfusion was initiated by quick cannulation into the left carotid and left subclavian arteries. Peripheral pressure was maintained above 80 mmHg with the flow of the selective cerebral perfusion at 1.0 L/min and flow from the femoral artery at 3.5 L/min. Hemi-arch replacement was performed using a Dacron graft. The body temperature passively descended to 35 °C. She normally delivered a healthy female baby after 37 weeks’ of gestation.     

Total Endovascular Debranching of the Aortic Arch

Background

Significant morbidity and mortality are related to conventional aortic replacement surgery. Endovascular debranching techniques, fenestrated or branched endografts are time consuming and costly.

Objective

We alternatively propose to use endovascular approach with parallel grafts for debranching of aortic arch.

Methods

Under general anesthesia, 12 F sheaths were inserted in the femoral, axillary and common carotid arteries for vascular accesses. ViaBahn grafts 10 – 15 cm in length were placed into the aortic arch from right common carotid, left common carotid and left axillary arteries, until the tip of each graft reached into the ascending aorta. Through one femoral artery, the aortic stent –graft was positioned and delivered. Soon after, the parallel grafts were sequentially delivered. Self-spanding Wallstents^R were used for parallel grafts reinforcement. Ballooning was routinely used for parallel grafts and rarely for aortic graft.

Results

This technique was used in 2 cases. The first one was a lady with 72 years old, with an aortic retrograde dissection from left subclavian artery and involving remaining arch branches. Through right common carotid artery a stent-graft was placed in the ascending aorta and through the left common carotid artery a ViaBahn was inserted parallel to the former. A thoracic endograft then covered all the aortic arch dissection extending into the ascending aorta close to the sinu –tubular junction. The second case was a 82 year old male patient with a 7 cm aortic arch aneurysm. Through both common carotid arteries ViaBahn grafts were introduced and positioned into the ascending aorta. Soon after, the deployment of the thoracic stent graft covered all parallel grafts of the aortic arch, excluding the aneurysm. Both cases did not have neurologic or cardiac complications and were discharged 10 days after the procedure.

Conclusions

This technique may be a good minimal invasive off-the-shelf technical option for aortic arch ‘‘debranching’’. More data and further improvements are required before this promising technique can be widely advocated.     

Acute type A aortic dissection and coarctation of aortic isthmus

Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.     

Is the axillary artery a suitable cannulation site in aortic surgery?

AIM: The axillary artery is currently gaining interest as an alternative to femoral artery cannulation in aortic surgery. It was the aim of our study to evaluate the feasibility, safety, and efficacy of axillary artery cannulation in a series of patients undergoing surgery of the ascending aorta and/or the aortic arch. METHODS: From 1998 to 2002 cardiopulmonary bypass (CPB) perfusion via the axillary artery was intended in 35 patients (28 male), median age 61 (22-77) years. The underlying disease was acute aortic dissection type A in 22/35 (63%), chronic aortic dissection type A in 2/35 (6%), ascending aortic aneurysm in 8/35 (22%), aortic regurgitation after previous ascending aortic replacement in 1/35 (3%), pseudoaneurysm after Bentall operation in 1/35 (3%) and coronary artery disease with severe arteriosclerosis of the aorta in 1/35 (3%). RESULTS: Conversion to femoral artery or ascending aortic cannulation was necessary in 3 patients. In the other cases, adequate CPB flows of 2.4 l/m2/min were achieved. In 1 case local dissection of the axillary artery occurred after emergency cannulation. No postoperative complications related to axillary artery cannulation, such as upper extremity ischemia, brachial plexus injury, or local wound infection occurred. No new postoperative stroke was noted, hospital mortality was 4/35 (11%) patients. CONCLUSION: Axillary artery cannulation is feasible in the majority of cases and seems to be a safe and effective method in surgery of the ascending aorta and aortic arch. Several disadvantages of femoral artery cannulation and perfusion can be avoided.     

Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection

PURPOSE: We describe a modular stent graft for use in endovascular repair of aneurysms of the aortic arch. METHOD: Carotid-carotid and left carotid-subclavian bypass grafts are created surgically. Two large, fully stented grafts are inserted endoluminally. The proximal component is bifurcated, with a wide proximal trunk and two distal limbs, one long and narrow, the other short and wide. This component is inserted through the carotid artery and deployed with the trunk and short wide limb in the ascending thoracic aorta; the long narrow limb opens into the innominate artery. After delivery system removal and carotid artery repair, a distal component is inserted through a femoral approach to bridge the gap between the short, wide distal limb of the proximal component and the nondilated descending thoracic aorta. The result is a branched stent graft, implanted proximally into the ascending aorta and distally into the innominate artery and descending thoracic aorta. CONCLUSION: The system has been used successfully to treat a large wide-necked pseudoaneurysm of the aortic arch.     

A case of ascending aortic pseudoaneurysm in a patient with aortic replacement

A 59-year-old man with a history of ascending aorta replacement for an aortic dissection using gelatin–resorcin–formalin glue at age of 50 years presented with paroxysmal nocturnal dyspnea. An echocardiogram showed severe aortic regurgitation associated with aortic root enlargement. Chest computed tomography showed that the ascending aorta was dilated and a pseudoaneurysm was observed around the implanted prosthetic graft. Upon opening the ascending aorta, we found that the posterior wall of the proximal anastomotic portion of the implanted graft was ruptured. After replacement of the aortic root with a composite graft and reconstruction of the orifices of the right and left coronary arteries, total arch replacement by the separated graft technique was performed. The postoperative course was uneventful.     

An unusual combination of cardiovascular surgical disorders

A 53-year-year-old man presented with aortic regurgitation, subvalvular and supravalvular aortic stenoses, and aneurysms involving the ascending aorta, the arch, and the innominate, right subclavian, and left common carotid arteries. Surgery consisted of resection of the obstructive lesions, replacement of the aortic valve, graft replacement of the ascending aorta, and the arch resection of innominate and subclavian artery aneurysms and reconstruction with a side limb to which the right carotid artery was anastomosed. The patient has remained asymptomatic with full employment.     

One step surgical repair of type II acute aortic dissection and aortic coarctation.

It is presented the case of acute type II aortic dissection in a patient with aneurysmal ascending aorta, hypoplastic arch and isthmic coarctation. One single step replacement of the ascending aorta, arch and the isthmus was performed by ensuring simultaneous optimal perfusion above and below the coarctation through the femoral and subclavian artery.     

Cardiac protection with systemic hyperkalemia in reoperations with patent grafts

A 68-year-old man with a history of coronary artery bypass graft surgery was admitted for ascending aorta replacement. Preoperative coronary computed tomography angiography revealed occlusion of the three coronary arteries. Perfusion of all three coronary vessels was achieved using a T-graft from the right gastroepiploic and radial arteries, which were anastomosed to the right coronary artery and posterolateral artery, respectively. The patient underwent ascending aorta replacement, with hyperkalemia and hypothermia for myocardial protection. Systemic hyperkalemia was useful to maintain cardiac arrest and also to monitor effective perfusion of the myocardium through the bypass grafts.     

Utilization of Triple-Lumen Balloon Catheter for Occlusion of the Ascending Aorta During Distal Aortic Arch Surgery with Hypothermic Retrograde Cerebral Circulation TechniqueThrough Left Thoracotomy

A technique of using a triple-lumen balloon catheter for occlusion of the ascending aorta in patients with distal aortic arch aneurysm during open proximal anastomosis utilizing hypothermic retrograde cerebral circulation technique through left thoracotomy was described. The balloon greatly facilitated (1) occlusion of the ascending aorta without cross clamping, (2) delivery of cardioplegic solution, (3) suctioning blood pooled in the aortic arch, and (4) prevention of entrance of debris into the left ventricle or coronary arteries.     

Direct cannulation of the common carotid artery during the ascending aortic or aortic arch replacement

Objective: To evaluate cerebral perfusion using direct cannulation into the common carotid artery. A new technique is needed to protect brain ischemic injury during ascending aortic or aortic arch replacement. Methods: This technique was evaluated for patients who would have difficulty maintaining adequate cerebral perfusion during surgery. The procedure was performed when patients had the following diagnoses: pseudoaneurysm formation in contact with the sternum with the risk of aneurysmal rupture (n=5), acute aortic dissection with compression of the true lumen of the innominate artery by the pseudolumen (n=3), or a large volume of thrombus in the lumen of the aneurysm with the risk of cerebral thromboembolism if standard extracorporeal circulation was used (n=2). The perfusion catheter was cannulated into one side of the common carotid artery (right side: n=6, left side: n=4) and mean perfusion flow rate was found to be 175 mL/min. The operative procedures consisted of ascending aortic and aortic arch replacement with coronary artery bypass grafting in six patients, ascending aortic replacement in 2 patients, and innominate artery reconstruction/innominate artery and right subclavian artery reconstruction in one patient. Results: No cerebral accidents or deaths occurred while patients were hospitalized. We have followed up patients for a mean of 2.1 years (maximum 3.6 years), with no complications noted from the surgical procedure. Conclusions: Direct cannulation of the common carotid artery is a simple, safe, and acceptable cerebral protection for patients undergoing aortic or aortic arch replacement procedures in the patients with these specific conditions.     

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30°C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.     

Single-stage repair for ascending aortic aneurysm,artery stenosis and occlusion of neck vessels caused by Takayasu arteritis

Takayasu arteritis results in a variety of vascular symptoms, and there are some cases in which progressive vascular lesions require surgical intervention. We present a case with ascending aortic aneurysm, right common carotid artery stenosis, left common carotid artery occlusion and left subclavian artery stenosis caused by Takayasu arteritis that was successfully treated with total arch replacement and ascending aorta to right internal carotid artery bypass.     

Simplified technique for aortic arch replacement. First-stage right subclavian-to-left carotid artery bypass

A simplified operative and perfusion technique for aortic arch replacement is described. Prior to definitive operation a right subclavian-to-left carotid artery bypass is performed using a Dacron graft. At the time of aortic arch replacement the right axillary artery is cannulated; this perfuses the right subclavian, right carotid, and left carotid arteries through the shunt, thus perfusing the entire brain. The rest of the body is perfused through a cannula in the femoral artery. This technique obviates the hazards and inconvenience of direct cannulation of the carotid arteries through the aneurysmal sac. The creation of such a shunt also reduces the time required for arch replacement, as the left carotid artery does not need a separate anastomosis.     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Acute intraoperative aortic dissection following axillary artery cannulation

We describe a 75-year-old woman who underwent right axillary artery cannulation in preparation for reconstruction of the aortic arch and the proximal descending aorta for athesosclerotic aortic aneurysm via a 'clamshell' incision. As soon as cardiopulmonary bypass was established, the ascending aorta and the aortic arch was dissected. The innominate artery was dissected including one-third of its circumferance anteriorly. Arterial perfusion was stopped immediately and the left femoral artery was cannulated to resume CPB. We proceeded with replacement of the ascending aorta, the aortic arch and the proximal descending thoracic aorta with a Dacron branched aortic graft. The patient recovered uneventfully. Arterial blood pressure was equal bilaterally.     

Repair of acute ascending aorta-arch dissection with continuous body perfusion: a case report

An approach for the replacement of the distal ascending aorta-proximal arch and acute dissection is described. During the operation, the patient's entire body was continuously perfused, the aortic arch was excluded from the arterial circulation, and the aorta was not clamped at any time. To achieve continuous body perfusion, we independently cannulated the right axillary and the left femoral arteries. The right atrium was cannulated for systemic venous return, and the right radial artery was used for arterial blood pressure monitoring. The myocardium was protected with retrograde cardioplegia, and the body was protected with moderate hypothermia. Vascular clamps were placed to the proximal innominate, left carotid, and left subclavian arteries without discontinuing perfusion of the right axillary artery. A temporary clamp was applied to the femoral line, the aorta was transected, and a large Foley catheter was inserted through the true aortic lumen. The Foley bulb was positioned in the proximal descending thoracic aorta and distended with saline until the aortic blood return ceased. The femoral line clamp was removed from the cannula, and the entire body was perfused during the completion of the distal aortic anastomosis. At the completion of the anastomosis, the Foley bulb was slightly deflated. Once the inserted graft was filled with blood, a large vascular clamp was applied to the graft, and the previously placed clamps were removed from the arch branches. The femoral line was removed, and the body was perfused and rewarmed via the axillary cannulation. Following completion of the proximal graft-aortic anastomosis, the heart was reperfused, and all cannulas were removed in the usual fashion. Rapid recovery characterized the patient's initial postoperative course; however, multiple organ failure secondary to pump-induced inflammatory response followed. Aggressive medical management resulted in complete patient recovery. No neurologic deficits were observed, and the patient regained full cognitive function. This report describes a simple approach to facilitate repair of the aortic arch and minimize postoperative organ failure.