Total arch replacement following partial replacement of the descending aorta for acute type A aortic dissection: report of a case

A 42-year-old man was admitted to our hospital due to severe back pain. A computed tomographic scan revealed aortic dissection from the ascending aorta to the left common iliac artery. His blood pressure was well controlled untill he went into shock 21 hours after the onset. He was given a diagnosis of aortic rupture to the left pleural cavity by echocardiography and chest X-ray. He underwent emergent left thoracotomy under femoro-femoral bypass. We found a rupture of the descending aorta 3 cm above the diaphragma and replaced the ruptured segment with a woven Dacron graft. On postoperative day 9, we performed total arch replacement utilizing deep hypothermia and selective cerebral perfusion. We located the entrance tear in the aortic arch. His postoperative course was uneventful and he showed no neurological deficit. He was discharged from the hospital on postoperative day 36.     

Successful management of a ruptured infected aneurysm of the thoracic aorta: report of a case

A successful removal of the infected thoracic aortic aneurysm ruptured to the lung is reported. A 59-year-old man who had been suffering from high fever showed sudden hemoptysis and shock during antibiotic therapy. Immediately a so-called temporary bypass grafting from ascending aorta to descending aorta was placed with a woven Dacron prosthesis, and then aneurysmectomy with upper lobectomy of the left lung was carried out. Finally the graft was left as a permanent bypass graft. In addition, the left subclavian artery was reconstructed with a EPTFE graft. The patient is now well one year after operation.     

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.     

A case report of ruptured mycotic aneurysm at the site of subclavian flap angioplasty]

Postoperative mycotic aneurysm of the thoracic aorta at the site of subclavian flap angioplasty (SFA) is very rare. A 6-year-old boy was admitted with a history of high fever for 10 days. He had undergone SFA at the age of 14 days and patch closure of VSD at 10 months. The chest X-ray film on admission revealed no abnormality. But, 7 days later, he suffered from frequent hemoptysis and chest X-ray film showed an abnormal mass shadow at the left upper lung field. Contrast enhanced CT scan and IV-DSA revealed a pseudoaneurysm of the aortic arch which had ruptured into the left upper lung. An extra-anatomical bypass was urgently made from the ascending aorta to abdominal aorta and the aneurysm was isolated by ligations of the aorta proximal and distal to the aneurysm. Aneurysmectomy combined with left upper lobectomy was carried out next day. Septic signs and hemoptysis dramatically improved after operation. Extra-anatomical bypass as a means of choice for the surgical treatment of the mycotic aneurysm greatly contributed to cure the severe ill patient. But a close follow up observation for the function of the graft is necessary.     

Emergent surgical treatment of type A acute aortic dissection in an elderly patient]

An 86-year-old man with severe chest pain and shock was transferred to our hospital. Computed tomography revealed type A aortic dissection with cardiac tamponade. He needed intubation and closed chest massage preoperatively. At operation, intrapericardial space was filled with clotted blood and rupture of the ascending aorta was confirmed. He underwent a successful emergency graft replacement of the ascending aorta. Postoperative course was uneventful except for mild hemianopsia due to cerebral infarction. He had recovered to be able to walk and is doing well.     

Cardiopulmonary bypass established via a sutured vascular graft in the presence of extraanatomic bypass

Cardiopulmonary bypass (CPB) was established via a sutured collagen sealed knitted Dacron graft in two patients who had undergone extraanatomic bypasses for lower limb ischemia, whose ascending aorta was not suitable for cannulation. One patient, with a history of femorofemoral bypass, underwent surgery for a ruptured aortic arch aneurysm (AAA) and the other patient, with a history of axillobifemoral bypass for chronic dissection involving the aortic arch and descending aorta, had unstable angina and underwent coronary artery bypass grafting. This technique of perfusion was found to be safe and effective for patients with an impaired ascending aorta who have undergone an extraanatomic bypass for the lower limb.     

Combined aortic valve replacement and coronary artery bypass grafting for a calcified ascending aorta

Although a severely calcified ascending aorta is encountered infrequently, it presents formidable problems during cardiac surgery. We describe a case of severe aortic valve stenosis and coronary artery disease combined with a severely calcified ascending aorta. The patient was an 80-year-old man with a calcified ascending aorta. He successfully underwent an aortic valve replacement and a single coronary artery bypass graft (CABG) using a saphenous vein graft with the proximal end connected on a Dacron patch, which was used for aortoplasty of the calcified plate along the aortotomy. These procedures were performed under moderate hypothermia with aortic clamping. This patch aortoplasty can be a useful alternative in cases that require aortotomy and proximal anastomoses of a CABG on a calcified ascending aorta.     

Emergent surgical management of aortic dissecting aneurysm, type A Stanford, complicated with acute cardiac tamponade; report of a case

A 52-year-old woman, who had been treated medically for 31 days with the diagnosis of type A aortic dissection, suddenly fell in shock because of acute cardiac tamponade. Emergent operation was performed two hours after the onset of shock. Entry and perforation were located in the ascending aorta. Ascending aorta was opened without cross-clamping under profound hypothermic low flow perfusion through femoral artery, and intraluminal grafting with a double ringed graft was completed. Combined technique of open distal anastomosis and ringed graft is useful in such an emergent case as cardiac tamponade of aortic dissection.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Successful surgical treatment of ruptured thoracic aortic aneurysm into the lung

A 62-year-old man was admitted to the hospital because of massive hemoptysis. Chest X-ray film, CT scan and IADSA demonstrated a large aneurysm of the thoracic aorta, extending from the ascending aorta to the descending aorta. Bronchoscopy revealed bleeding from left B1+2. Six days after the onset, replacement of the thoracic aorta with woven Dacron prosthetic graft, autoclaved after immersion in albumin, was performed with cardiopulmonary bypass and separate cerebral perfusion (700 ml/min) under moderate hypothermia (25 degrees C). Left upper lobe of the lung, adherent tightly to the posterior and medial wall of the aneurysm, was not dissected because bleeding from left bronchus was trivial even after systemic heparinization. Because of the cardiac dilatation, delayed chest closure was needed. Postoperative cardiac failure, necessitating much catecholamine support, was seen with gradual improvement and no neurological deficit was recognized. He was discharged from the hospital without any sequelae 2 months after the onset. Pathologic diagnosis was an atherosclerotic 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.     

A successful surgical case of thoracoabdominal aortic aneurysm ruptured into the right pleural cavity]

A 55-year-old man was transferred to our cardiovascular center because of right hemothorax and hemorrhagic shock. Emergency CT scan revealed a thoracoabdominal aortic aneurysm (Crawford's type I-A) ruptured into the right thorax. The aneurysm was exposed by Stoney's spiral opening approach. A 24 mm Cooley Dacron graft was implanted in end-to-end fashion between the descending thoracic aorta and the abdominal aorta just above the celiac artery. The use of aortic artery cannula, femoral artery cannula and flexible polyvinyl tube provided safe and simple means as a temporary bypass during this graft replacement. Postoperative course was uneventful.     

A Case of Ruptured Desceding Thoracic Aortic Aneurysm Due to Salmonella Infection

A 66-year-old male was admitted to our hospital because of pyrexia, chest pain and hemosptum. Inflammatory findings were made and salmonella enteritidis was detected by bacterial examination of sputum and stool. Enhanced chest CT examination disclosed a descending thoracic aortic aneurysm which had ruptured into the left lower lobe of the lung. Under a diagnosis of ruptured mycotic descending thoracic aortic aneurysm, an emergency operation was performed. A left posterolateral thoracotomy carried out after axillo-bilateral femoral bypass grafting. A pseudoaneurysm of the descending thoracic aorta had ruptured into the left lower lobe of the lung. After resection of the aneurysm, closure of both ends of the intact descending thoracic aorta and a left lower lobectomy were carried out. An ascending aorta-infrarenal abdominal aorta bypass was performed because of insufficien visceral arterial blood flow through the axillo-bilateral femoral bypass. The patient’s immediate postoperative recovery was complicated by paraplegia. Chloramphenicol and levofloxacin were administered for three months, after which his recovery followed a good course.     

Aneurysm of the left sinus of Valsalva producing obstruction of the left main coronary artery and aortic regurgitation

A 50-year-old male was admitted with dyspnea on exertion and palpitation. On physical examination, a grade 2/6 aortic regurgitant murmur was heard at the left sternal border. A chest roentogenogram showed an oval shadow on the left cardiac border. Digital subtraction angiogram, aortogram and coronary arteriogram revealed an unruptured-large aneurysm of the left sinus of Valsalva, which compressed the left main coronary artery and produced aortic regurgitation. Surgical correction consisted of obliteration of the orifice of the aneursym with woven Dacron graft patch, aortic valve replacement using SJM23A, and a saphenous vein bypass from the ascending aorta to the left anterior descending coronary artery. Postoperative studies showed complete obliteration of the orifice of the aneurysm, a patent aorto-coronary bypass graft and no perivalvular leakage. This aneurysm was considered congenital in origin, because of no inflammatory and infectious evidence, negative serologic test for syphilis and no aneurysmal dilatation of the ascending aorta.     

False aneurysm of the ascending aorta concomitant with chronic mediastinitis after tube graft replacement in octogenarian.

An 81-year-old man developed impending rupture of a false aneurysm of the ascending aorta concomitant with chronic mediastinitis lasting for 10 years after tube graft replacement. He had undergone various infection-related mediastinal surgical procedures. He was successfully treated by debridement of infected tissues, patch repair of the false aneurysm, and transposition of the right latissimus dorsi muscle flap. The postoperative course was uneventful except for seromas. A chest computed tomographic scan performed 5 and 24 months after surgery showed no signs of recurrent aneurysm formation. A conservative surgical treatment including muscle flap transposition was effective in octogenarian.     

A successful surgical treatment of acute dissecting aneurysm of the ascending aorta: repair of the proximal intimal tear necessitating bypass for the right coronary artery

This is a case report of the successful surgical treatment of acute dissecting aneurysm of the ascending aorta. The patient was a 65-year-old female, who admitted to the hospital 3 hours after the onset of severe back pain. Enhanced CT of the chest and abdomen revealed acute dissection of the ascending aorta from its origin to the bilateral common iliac arteries. Thirteen hours initiation of the symptoms, operation was carried out using pump-oxygenator with hypothermia. Transverse incision of the ascending aorta revealed acute dissection in anterior aspect extending to two third of the circumference. The proximal small intimal tear was found 3 mm apart from the right coronary artery ostium. Upon closure of the tear resulting in obliteration of the right coronary artery, it required bypass procedure between the right coronary artery and the innominate artery using the saphenous vein graft. The aortic incision was directly closed using Dacron felt bolsters. Postoperative studies revealed disappearance of the proximal aortic dissection, patency of the bypass graft and existence of distal aortic dissection. Patient is in active life 6 months after operation.     

Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results

BACKGROUND: We analyzed our 22 years of experience with extraanatomic bypass grafting for repair of aortic arch coarctation in adults. Results from early and midterm follow-up with clinical evaluation and magnetic resonance angiography are reported. METHODS: Between November 1979 and December 2001, 18 consecutive patients aged 18 to 61 years (mean, 31.8 +/- 13.3 years) underwent extraanatomic bypass grafting to repair coarctation of the aortic arch. Six patients (33.3%) had recoarctation after previous repair through a left thoracotomy, and 3 (16.7%) had associated cardiac diseases. The operative technique used in all patients was ascending aorta-to-descending thoracic aorta bypass with a polyethylene terephthalate fiber (Dacron) graft through a median sternotomy and posterior pericardial approach. RESULTS: Follow-up was completed in all patients, with a mean duration of 5.6 +/- 5.7 years (range, 12 months to 22 years). The follow-up interval exceeded 10 years in 5 patients. No neurologic complications, early or late mortality, late reoperations, or graft complications occurred. Six patients (33.3%) had mild hypertension. All patients were asymptomatic with patent Dacron grafts confirmed by echocardiography. Magnetic resonance angiography, performed in 15 (83.3%) patients, revealed that the Dacron grafts were still patent at a mean interval of 4.0 +/- 6.2 years (range, 5 days to 22 years) after repair. CONCLUSIONS: Extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic arch coarctation in adults is safe, with low morbidity and no mortality. The favorable midterm results indicate this technique is a safe and less invasive means of repairing aortic arch coarctation or recoarctation in adults.     

Late pseudoaneurysm formation after patch angioplasty of coarctation of the aorta; report of a case

We report a case of a 13-year-old boy presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair a coarctation of the aorta. At the age of 3 months, he had undergone patch angioplasty for a coarctation of the aorta, which develops following patent ductus arteriosus division at 2 months of age. He was treated by distal aortic arch replacement using 16 mm woven Dacron tube graft in an end-to-end fashion with open proximal anastomosis under deep hypothermic circulatory arrest. The aneurysm was in the aortic wall opposite the patch graft. There was no evidence of infection or dilatation of the patch graft. This case illustrates that repair of aortic coarctations with Dacron patches cannot be recommended.     

Intra-graft balloon pumping--a clinical case report]

A 29-year-old female underwent tube graft replacement of distal aortic arch and descending aorta for dissecting aneurysm. After 42 minutes of aortic cross-clamping the patient was initially weaned satisfactorily from cardiopulmonary bypass (CPB). However, cardiac arrhythmia and cardiac arrest necessitated reestablishment of CPB. Electro-cardiography showed inferior myocardial infarction. To wean CPB intraaortic balloon pumping (IABP) was mandatory. But because of dissecting aortic aneurysm IABP in conventional method was contra-indicated. Intra graft balloon pumping (IGBP) was initiated while the patient was on full CPB. A low-porosity woven Dacron tube graft (22 mm) was anastomosed end-to-side to ascending aorta. A balloon was inserted into the tube graft to establish IGBP. This IGBP provided effective circulatory assist. The patient was weaned from CPB 1 hours after reestablishment of IGBP. Postoperative course was stable. The patient was returned to the operating room for removal of the balloon 3 days postoperatively. We reported the case for whom IGBP was effective. IGBP was effective circulatory support for the patient when conventional use of IABP was contra-indicated.     

A case report of simultaneous procedure of Cabrol's operation and aortic arch replacement: method to reduce the duration of ischemic cardiac arrest]

A 57-year-old female underwent simultaneous Cabrol's operation and aortic arch replacement for aortic dissection. She was admitted with complaint of back pain. Aortography demonstrated acute dissecting aneurysm of the ascending, arch and descending aorta (DeBakey type I) as well as aortic valve regurgitation (Seller's II degree). The operation was undertaken using cardiopulmonary bypass (CPB) under hypothermia with selective cerebral perfusion. A new method to reduce the duration of ischemic cardiac arrest was applied. Initially a low-porosity woven Dacron tube graft (8 mm) was anastomosed to coronary arteries. Blood of CPB was perfused to this graft. This coronary perfusion contributed to shorten ischemic cardiac arrest time and cardiac function was favorable. This method to reduce the duration of ischemic cardiac arrest brought about good result.