Successful surgery for an acute type A aortic dissection following repair of a descending thoracic aortic aneurysm

Acute type A aortic dissection in the presence of a previously repaired atherosclerotic descending thoracic aortic aneurysm is rarely reported. We experienced a patient who underwent an ascending aortic replacement with reconstruction of the aortic arch 16 months after repair of a descending thoracic aortic aneurysm. We succeeded in the redo operation with comprehensive techniques involving selective cerebral perfusion, deep hypothermia, early antegrade systemic circulation for cerebral protection, and femoro-femoral bypass with occlusion of the descending aorta for lower systemic perfusion as well as renal perfusion. The patient recovered and is doing well one year after the redo operation.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade; report of a case

The ruptured aortic arch aneurysm with cardiac tamponade is rare and has severely high mortality. We report a case of ruptured aortic arch aneurysm with cardiac tamponade. A 66-year-old man who had syncope attack was transferred to city hospital. Brain computed tomography (CT) showed no significant lesion and he admitted to our hospital for suspecting of aortic dissection. Chest CT showed ruptured aortic arch aneurysm and pericardial effusion. Emergent operation was done on the same day. It was found that the hematoma beneath the tunica adventitia existed at the distal arch and extended to the ascending aorta. Cardiac tamponade was caused by rupture of subadventitial hematoma in pericardial space. Aortic arch replacement was performed using selective cerebral perfusion under deep hypothermia. Postoperatively, he had no cerebral complication and was discharged uneventfully.     

Ruptured thoracic aortic aneurysm complicated by acute aortic dissection and aortic valve regurgitation; report of a case

An 87-year-old man was found loss of consciousness after falling. He was found in a state of shock. Computed tomography showed rupture of aneurysm of the ascending aorta and aortic arch with acute aortic dissection. Echocardiography revealed aortic valve regurgitation and cardiac tamponade. As the result of emergency operation, a large hematoma in the mediastinum and pleural cavity as well as massive serous pericardial effusion were found. The dissection was seen in aneurysm of the ascending aorta and aortic arch with an intimal tear located in the aortic arch. After aortic valve replacement was performed, the ascending aorta and aortic arch were replaced, and reconstruction of 3 cervical vessel branches was performed under deep hypothermic circulatory arrest with selective cerebral perfusion. Despite the complex clinical state and serious condition in the elderly patient, emergency surgery saved the life of the patient without complications.     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

A case of the ascending aorta and aortic arch replacement with thrombo-occlusion of distal arch and descending aorta suround the modified elephant trunk graft

We report a 65-year-old female who had a extensive thoracic aneurysm from ascending aorta to descending thoracic aorta. The patient underwent a graft replacement of ascending aorta and aortic arch using modified elephant trunk method. The surgery was carried out through median sternotomy with profound hypothermia and selective cerebral perfusion. Postoperatively, the patient was recovered without any complications except bronchial asthma. Postoperative chest computed tomography showed that the surrounding space of the elephant trunk vascular graft inserted into distal arch and descending aneurysm was mostly occupied with thrombus. Therefore, we considered that the second operation on the descending aorta is not necessary at this point and careful attention to the size and shape of the descending aneurysm should be paid.     

Nine years experience of aortic arch repair with the aid of antegrade selective cerebral perfusion

AIM: Antegrade selective cerebral perfusion (ASCP) is gaining widespread popularity in aortic arch surgery because it has been demonstrated to be an optimal technique of cerebral protection. This study demonstrates the clinical results of aortic arch repair with ASCP. METHODS: Between November 1996 and September 2004, 250 patients underwent thoracic aorta replacement using ASCP under moderate hypothermia. Mean patients age was 63+/-11.5 years. Presenting pathologies were chronic aneurysm in 136 patient (54.4%), type A acute aortic dissection in 80 patients (32%), post-dissection aneurysm in 30 patients (12%). Ascending aorta and hemiarch replacement was performed in 63 patients (25.2%), ascending aorta and total arch replacement in 131 patients (52.4%), total arch replacement in 33 patients (13.2%), total arch and descending aorta replacement in 10 patients (4%) and complete replacement of the thoracic aorta in 13 patients (5.2%). RESULTS: Hospital mortality was 11.6%. Multivariate analysis showed preoperative renal failure (P=0.050), cerebral perfusion time (P<0.001), pulmonary complications (P=0.009) and postoperative dialysis (P=0.030) as risk factors for hospital mortality. Permanent neurologic deficits occurred in 4 patients (1.6%) and coronary artery disease (P=0.029) was found to be the only independent risk factor. Transient neurologic deficits were noted in 18 patients (7.2%). Multivariate analysis revealed age (P=0.043), coronary artery disease (P=0.036), urgent/emergency status of the operation (P=0.016) and concomitant aortic valve replacement (P=0.001) to be independent predictors of transient neurologic dysfunction. The actuarial survival rate at 7 years was 61.7%. CONCLUSIONS:| Our results confirmed that ASCP is a safe method of brain protection allowing complex aortic repairs to be performed with good results in terms of hospital mortality and neurologic outcome. Cerebral perfusion time did not influence postoperative outcome. The use of moderate hypothermia avoided all undesirable effects of deep hypothermia.     

Arch repair with unilateral antegrade cerebral perfusion.

OBJECTIVE: Several antegrade cerebral perfusion techniques with differing neurological outcomes are employed for aortic arch repair. This study demonstrates the clinical results of aortic arch repair with unilateral cerebral perfusion via the right brachial artery. METHODS: Between January 1996 and March 2004, 181 patients underwent aortic arch repair via the right upper brachial artery with the use of low-flow (8-10 ml/kg per min) antegrade selective cerebral perfusion under moderate hypothermia (26 degrees C). Mean patient age was 58+/-12 years. Presenting pathologies were Stanford type A aortic dissection in 112, aneurysm of ascending and arch of aorta in 67, and isolated arch aneurysm in two patients. Ascending and/or partial arch replacement was performed in 90 patients and ascending and total arch replacement in 91 patients (including 27 with elephant trunk). In a subset of patients, renal and hepatic effects of ischemic insult were assessed. Free hemoglobin and lactate dehydrogenase levels were measured pre and postoperatively to identify hemolytic effects of brachial artery cannulation. RESULTS: Mean antegrade cerebral perfusion time was 36+/-27 min. Three patients with acute proximal dissection died due to cerebral complications. One patient had transient right hemiparesis. Total major neurological event rate was 2.2%. Brachial artery was able to carry full cardiopulmonary bypass flow with mild hemolysis. Renal and hepatic tests showed no deleterious effects of limited ischemia at moderate hypothermia. CONCLUSIONS: Arch repair with antegrade cerebral perfusion through right brachial artery has excellent neurological results, provides technical simplicity and optimal repair without time restraints, does not necessitate deep hypothermia and requires shorter CPB and operation times.     

Aortic arch repair with right brachial artery perfusion

Background. To determine the effectiveness of unilateral selective cerebral perfusion for aortic arch repair and to discuss possible modifications to enhance technical simplicity.

Methods. In the period between January 1996 and April 2001, 104 patients underwent aortic arch repair with the use of right brachial artery low flow (8 to 10 mL/kg per minute) antegrade selective cerebral perfusion under moderate hypothermia (26°C). Mean patient age was 52 ± 12 years. Sixty-four patients presented with Stanford type A aortic dissection, including 12 with acute dissection; 38 patients had aneurysmal dilatation of the ascending aorta and aortic arch; and 2 patients had isolated arch aneurysm. Ascending and partial arch replacement was performed in 50 patients; ascending and total arch replacement in 33 patients; ascending and descending arch replacement in 19 patients; and isolated arch replacement in 2 patients.

Results. Mean antegrade cerebral perfusion time was 39 ± 22 minutes. One patient with acute proximal dissection died because of cerebral complications. One other patient developed right hemiparesis, which resolved during the second postoperative month without sequela. Other than these 2 cases (1.9%), no other neurologic event was observed.

Conclusions. The technique of low flow antegrade selective cerebral perfusion through the right brachial artery may be used for a vast majority of aortic aneurysms and dissections requiring arch repair. This technique does not necessitate deep hypothermia, requires shorter cardiopulmonary bypass and operation times, has the advantage of simplicity, provides optimal vascular repair without time restraints and, in terms of clinical results, is as safe as other techniques for cerebral protection.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

Cardiac transplantation and simultaneous surgical repair of an aortic aneurysm.

Simultaneous cardiac transplantation and surgical repair of an aortic aneurysm has not been reported previously. At our institution, a 59-year-old patient with an aneurysm of the ascending aorta and aortic arch required orthotopic cardiac transplantation for end-stage cardiomyopathy. He underwent successful surgical replacement of his ascending aorta and transverse arch (in circulatory arrest and deep hypothermia) at the time of heart transplantation.     

Ruptured distal aortic arch aneurysm associated with arteriosclerosis obliterans.

A 73-year-old man with a ruptured distal aortic arch aneurysm into the pericardial space, mediastinum and right pleural space is described. The patient underwent a successful total aortic arch replacement using deep hypothermia, systemic circulatory arrest and selective cerebral perfusion. Extracorporeal circulation was established with right axillar arterial perfusion due to arteriosclerosis obliterans (ASO). Presentation and management are discussed.     

Delayed retrograde aortic dissection after endovascular stenting of the descending thoracic aorta

A 66-year-old patient underwent emergency endovascular repair of a descending thoracic aneurysm because of suspected aortic rupture. Two weeks later, a small saccular aneurysm of the aortic arch was treated with open surgery. An unexpected intraoperative finding was retrograde dissection of the aortic arch and of the ascending aorta that was not seen on the postprocedural computed tomographic scans after endografting. The ascending aorta, the aortic arch, and the proximal part of the descending thoracic aorta were successfully replaced with a Dacron graft with deep hypothermia, circulatory arrest, and retrograde cerebral perfusion. Awareness that this life-threatening complication that necessitates extensive cardiovascular surgery can occur not only during or immediately after endovascular stenting of the thoracic aorta but also as much as several days or perhaps even weeks after the procedure is important.     

Combined heart transplantation and resection of dissecting aneurysm of ascending aorta and aortic arch: a case report.

A 21-year-old male patient had suffered from palpitation and exertional dyspnea since October, 1997. He was admitted to our hospital, and a series of examinations were performed. Chest computed tomography (CT) revealed marked dilatation of the ascending aorta (about 7.5 cm at the proximal portion) and aortic annulus, an intimal flap in the ascending aorta and aortic arch was also noted. Cardiac catheterization revealed the pulmonary capillary wedge pressure was 33 mmHg, pulmonary artery pressure was 47/38 mmHg with a mean of 35.4. The cardiac index was 1.01 l/min/m2. Poor left ventricular contractility was shown by a left ventricular ejection fraction (LVEF) of 13.8% and a right ventricular ejection fraction (RVEF) of 5.13% by a radionuclide angiogram (RNA) study. Under the diagnosis of dilated cardiomyopathy and dissecting aortic aneurysm of the ascending aorta and aortic arch, he was put on a waiting list for heart transplantation. On November 11, 1997 he received heart transplantation. Resection of the dissecting aneurysm of the ascending aorta and the aortic arch and replacement with a 26 mm Vascutek graft were performed first under deep hypothermia and retrograde cerebral perfusion. Then while he was rewarming up, heart implantation was performed. He was discharged 30 days after surgery and has been doing well since then. As far as we know, no literature regarding combined heart transplantation and resection of a dissecting aneurysm of the ascending aorta and aortic arch has been reported.     

Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta

OBJECTIVE: Cerebral complication is still a major concern in surgery for arteriosclerotic aortic arch disease. For preventing this complication, axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and arch aorta were applied to thoracic aortic aneurysm involving aortic arch. METHOD: From May 1999 to July 2002, consecutive 39 patients with true aneurysm (29 patients) or chronic aortic dissection (10 patients) involving aortic arch underwent replacement of the ascending and arch aorta with an elephant trunk under hypothermic cardiopulmonary bypass through the axillary artery cannulation and selective cerebral perfusion. The brain was continuously perfused without any intermission through the axillary artery. Concomitant operation included coronary artery bypass grafting (CABG) in two patients, aortic valve replacement (AVR) in one, Bentall operation in two, mitral valve replacement (MVR) in one, and aortic valve sparing operation in one. Patient age at operation was 40-84 (72 + 9) years and 24 of them were older than 70 years of age. RESULTS: There was one operative death (2.5%) due to bleeding from the left lung, and one hospital death due to respiratory failure. Postoperative permanent neurological dysfunction was found in one patient (2.5%). Two patients presented temporary neurological dysfunction (5%). Thirty-six of the 39 patients were discharged from hospital on foot. CONCLUSION: Continuous perfusion through the axillary artery with selective cerebral perfusion and replacement of the ascending and arch aorta may minimize cerebral complication leading to satisfactory results in patients with chronic aortic aneurysm involving aortic arch.     

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.     

Spinal cord ischemia after surgery for arch and aortic valve replacement with elephant trunk for plural thoracic aneurysms

A 62-years old man had plural aneurysms from the aortic arch to the descending aorta. Y-grafting had been performed twice for an abdominal aortic aneurysm. We performed the first operation which involved aortic valve and arch replacement under deep hypothermia with selective cerebral perfusion. During the operation, hemodynamics was stable, but after the operation he developed paraplegia due to ischemic change in the spinal cord. It was considered that the cause of the ischemia might have been the changing of the blood supply to the spinal cord. In patients with severe atherosclerosis, the blood supply for the spinal cord needs to be very strictly determined.     

Graft replacement from ascending aorta to descending aorta with endovascular stent graft under median sternotomy]

We reported a 62-year-old man with DeBakey IIIa dissecting aortic aneurysm involving distal aortic arch who underwent graft replacement from ascending to descending aorta using a endovascular stent graft. Median sternotomy was carried out, because of severe pleural adhesion. Endovascular stent graft composed of 30 mm Gianturco Z stent and 24 mm woven Dacron graft was inserted to descending aorta with the aid of hypothermia, systemic circulation arrest and selective cerebral perfusion. Transesophageal echocardiography was used to measure the diameter and the length of descending aorta and the graft. And ascending and total aortic arch replacement was performed with four branched woven Dacron graft. Postoperative chest CT and aortography showed satisfactory reconstruction with the thrombosed false lumens. We think placement of stent graft to descending aorta through median sternotomy is useful method when left thoracotomy is impossible or distal anastomotic site is too far for the anastomosis.     

Concomitant aortic arch and root replacement using a stentless xenograft for acute type a dissection

A 78-year-old woman with an aortic root aneurysm and aortic regurgitation developing acute type A dissection successfully underwent aortic root replacement using a stentless xenograft during core cooling, followed by total aortic arch replacement under selective cerebral perfusion with deep hypothermia. This bioprosthesis can be used in the same way as a free-hand homograft and potentially provides an aggressive, safe option for acute aortic dissection requiring aortic root reconstruction in elderly patients.     

一期次全或全主动脉替换术的临床应用

目的 总结全主动脉替换术治疗全程主动脉瘤及慢性Stanford A型主动脉夹层的临床经验。方法 2004年2月至11月对8例全程主动脉瘤或慢性Stanford A型主动脉夹层的患者施行一期次全（2例）或全主动脉替换术（6例）。其中7例男性,1例女性,年龄23～47岁。病因均为马凡综合征。手术均在全身麻醉深低温停循环顺行性脑灌注下进行。采用左后外胸腹联合切口及胸骨正中切口。手术采用四分支人工血管,先行升主动脉替换或Bentall手术,然后行主动脉弓替换,最后完成胸腹主动脉替换。结果 无手术及住院死亡。1例脑梗死。随访2～12个月,无晚期死亡及再手术病例。结论 一期次全或全主动脉替换术可减少分期手术的痛苦,节约医疗费用,并消除分期手术残余动脉瘤破裂的风险,是治疗全程主动脉瘤及慢性Stanford A型主动脉夹层的有效方法。     

Moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in ascending aorta and aortic arch surgery. Preliminary experience in twenty-two patients

Deep hypothermic cardiocirculatory arrest is the commonest method of brain protection during transverse aortic arch surgery. Its principle drawbacks consist in the limited safe ischemic period and in the coagulative, renal and pulmonary complications related to low body temperatures and prolonged cardiopulmonary bypass time. Different selective cerebral perfusion techniques have recently raised the interest of some surgical teams in an effort to obviate these problems. The authors' initial experiences with 22 patients, ranging in age from 19 to 78 years (mean, 55±15 years), who underwent ascending aorta and/or aortic arch replacement using selective cerebral perfusion and moderately hypothermic cardiopulmonary bypass are reported here. Acute aortic dissection and atherosclerotic aneurysm were the commonest lesions observed: ascending aorta associated with partial or complete arch replacement was the most widely performed procedure. With regard to the perfusion technique, after regular cardiopulmonary bypass had been established through the iliac vessels, selective cerebral perfusion was started after aortic arch vessels cannulation (innominate artery, bilateral common carotid artery, innominate artery and left common carotid artery, or right common carotid artery) using a single roller pump separately from the systemic circulation, and brain perfusion was achieved by blood cooled at 30°C, at a flow rate that ranged from 300 ml/min to 1500 ml/min, at a perfusion pressure of ~65 mmHg, with the patient maintained at moderate hypothermia (30°C rectal). To perform distal aortic repair, if transverse aortic arch or proximal descending aorta cross-clamping was not feasible, cardiopulmonary bypass flow was lowered to 300–350 ml/min and an open anastomosis was performed, while independently assuring cerebral perfusion (six patients). There were three hospital deaths (mortality rate of 13.6%; s.d. 6.0–25.5%; 70% confidence limit), but none because of cerebral accident. No paraplegia occurred. One patient suffered from right hemiparesis, neither renal nor pulmonary complications were observed. Two chest reexplorations were necessary for bleeding, which were partially related to hemocoagulative disorders. In our experience, the technique of moderately hypothermic cardiopulmonary bypass and selective cerebral perfusion in aortic surgery has provided good results with regard to cerebral protection and organ function preservation. Therefore, allowing a prolonged distal aortic reconstruction period, it may be considered as a safe alternative to profound hypothermia associated with cardiocirculatory arrest in aortic arch surgery.