Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Simultaneous multi-vessel coronary artery bypass grafting, ischemic mitral regurgitation repair and descending aortic aneurysm replacement: analysis of technical points

The combination of coronary artery disease and its complications (ischemic mitral regurgitation etc.) with the aneurysm of the descending thoracic aorta is not a rare case. The single-stage correction of coronary/intracardiac/aortic lesions may be considered as a way of managing the combined patients. Simultaneous multi-vessel coronary artery bypass grafting, suture mitral annuloplasty and descending aortic aneurysm replacement with synthetic prosthesis is described. The operation was performed through the left thoracotomy with cardiopulmonary bypass established by the cannulation of the ascending aorta and of the right atrial appendage. Ventricular fibrillation and no clamping of the ascending aorta were used. The circulatory arrest was induced for the construction of the proximal anastomosis between the descending aorta and the synthetic prosthesis. No complications related to the operation were diagnosed for the 14-month follow-up. Several technical points seem optimal for the combined procedure: (1) Minimization of manipulations on the ascending aorta (using of pedicled left internal thoracic artery; construction of the proximal anastomoses with synthetic aortic prosthesis; unclamped ascending aorta). (2) Revascularization of all coronary areas and correction of intracardiac lesions through the left thoracotomy. Individual planning of the procedural technical points for every patient may provide a safe feasibility of the combined procedure.     

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.     

Right aortic arch with mirror-image branching and coarctation of the aorta--a case report]

The right aortic arch with coarctation of the aorta was reported. A 56-year-old woman admitted to the hospital because of headache and hypertension. Cardiac catheterization revealed the right aortic arch with coarctation of the aorta and 80 mmHg pressure gradient across the coarctation. The bypass operation with a 14 mm Dacron graft between the ascending to descending aorta was performed. There was no peak systolic pressure gradient between the ascending and descending aorta after bypass operation. This patient is the fourth case report with both mirror-image type right aortic arch and coarctation of the aorta.     

A case of coexisting descending thoracic aortic aneurysm and atypical aortic coarctation treated successfully by surgery using the thromboexclusion method

The thromboexclusion method was successfully applied to a 43-year-old male with aortitis syndrome. Preoperative aortogram showed a fusiform aneurysm of the descending aorta just below the left subclavian artery and atypical coarctation of the descending aorta distal to this aneurysm. Pressure gradient across the stenosis was about 70 mmHg. The technique of flow reversal and thromboexclusion was performed in this patient because of severe calcification in the aortic arch and the entire descending aorta. A long extra-anatomical bypass between the ascending aorta and the infrarenal abdominal aorta was made, and a permanent aortic clamp was placed across the aorta at the left subclavian artery. Hypertension in the arm disappeared immediately after the operation, and postoperative catheterization revealed no pressure gradient between the ascending and the abdominal aorta. Computed tomogram performed 18 days after the operation and aortogram done 44 days postoperatively disclosed thrombi formation in the aneurysm.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

A case of ascending aortic aneurysm with intrathoracic goiter

A case of the successful operation for ascending aortic aneurysm and intrathoracic goiter was described. A 71-year-old woman was admitted to our hospital for the treatment of ascending aortic aneurysm disclosed by the examination in another hospital. Preoperative chest CT showed ascending aortic aneurysm as large as 8 cm in diameter, and an upper mediastinal tumor compressing the main bronchus. The tumor was continuous with the right lobe of the thyroid. The excision of the tumor was performed through median sternotomy with cervical collar incison. After that, the replacement of the ascending aorta was carried out under cardiopulmonary bypass and hypothermic circulatory arrest. The histological examination of the resected specimen revealed adenomatous goiter without malignancy.     

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.     

Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy

BACKGROUND: Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS: Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS: No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS: Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.     

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.     

Aneurysm of the ascending aorta in its coarctation

In long-term period after resection of aorta coarctation, 9-14% patients developed aortic aneurysms, one third of them localized in the ascending aorta. From 146 patients operated on for aneurysm of the ascending aorta, 3 had aortic coarctation. In 2 patients aneurysms of the ascending aorta formed late after resection of the coarctation, the third patient was hospitalized with clinical picture of cardiac insufficiency at terminal stage due to coarctation of the aorta and a giant aneurysm of the ascending aorta with significant aortic insufficiency. The patients underwent successful surgeries: 1) ascending aorta grafting; 2) aortic valve and ascending aorta grafting by Bentallo de Bono method; 3) aortic valve and ascending aorta grafting by Bentallo de Bono method with bypass of descending aorta from the conduit. Cystic medianecrosis and two-volume aortic valve were revealed in all the patients. It is concluded that patients after surgery for coarctation of the aorta require long-term follow-up to defect cardiovascular complications early.     

Surgery of the dissecting aneurysm involving a right aortic arch

A dissecting aneurysm in association with a right aortic arch is extremely rare. However, a 50-year-old male was diagnosed as having a dissecting aneurysm (DeBakey IIIa) with a right aortic arch, right descending aorta and an aberrant retro-esophageal left subclavian artery. A graft replacement of the right descending aorta was successfully performed under right thoracotomy and partial cardiopulmonary bypass. Precise anatomical definition and proper surgical procedure permitted a successful surgical result.     

Surgical treatment of ruptured aneurysms of the innominate artery

The cases of 3 patients with an aneurysm of the innominate artery treated surgically are reported. The clinical manifestations were different, and the surgical procedures employed also varied. In 1 patient, the neck of the aneurysm was isolated and clamped near the aortic arch. It was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. In the second, the aneurysm was resected under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest. The neck was closed with a large Teflon patch, and a tube graft was interposed between the ascending aorta and the right carotid artery. In the third, a graft was interposed between both carotid arteries; conventional cardiopulmonary bypass was instituted, and the aorta was clamped between the innominate and the left carotid arteries. The neck of the aneurysm was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. All patients had an excellent postoperative course. Our comments regarding the clinical and surgical aspects of this condition are based on the present experience and reports in the literature.     

Aneurysm of the sinus of Valsalva producing obstruction of the left main coronary artery.

An aneurysm of the left sinus of Valsalva compressed the left main coronary artery and the patient experienced anginal pain. Surgical correction consisted of obliteration of the orifice of the aneurysm, aortic valve replacement, and a saphenous vein bypass from the ascending aorta to the distal left anterior descending coronary artery. Postoperative studies revealed excellent function of the prosthetic valve, no recurrence of the aneurysm and retrograde filling of the left anterior descending and circumflex coronary arteries. Three years after the operation, the patient is asymptomatic.     

Thoracic aneurysm expansion secondary to collateral supplies via thyrocervical trunk and intercostal arteries in a patient after thromboexclusion.

A case of thoraco-abdominal aortic aneurysm complicated after permanent clamping of the descending aorta (thromboexclusion) is reported. Angiographic and operative findings were: (1) a pseudo-aneurysm right at the distal anastomosis of previous intrathoracic bypass for pseudo-coarctation of the aorta filled by left ninth intercostal artery, which was supplied by the left internal thoracic artery; and (2) the cervical and thoracic spinal cord were supplied by the left vertebral artery and the mediastinal branch of the left thyrocervical trunk. This rare cause of a thoraco-abdominal aortic aneurysm and the significance of the subclavian artery as a source of spinal cord blood supply are discussed.     

Endovascular repair of descending thoracic aortic aneurysm via midsternotomy and without extracorporeal circulation

A 68-year-old man with peripheral vascular disease and associated risk factors, was diagnosed by CT-scan and aortography with an atherosclerotic descending thoracic aortic aneurysm. The patient was treated by successful endovascular grafting of the aneurysm using a midsternotomy incision and the insertion of a thoracic stent-graft through a T-Dacron tube sutured in the ascending aorta, without the aid of cardiopulmonary bypass.     

“Descending aortic aneurysm with acute type III dissection in a postpartum patient”

Acute aortic dissection and rupture of aneurysm is quite rare in the young. A 26-year-old woman (non-Marfan) presented with anemia and massive left sided hemothorax in her early postpartum period. She was diagnosed to have acute Type III aortic dissection with rupture of thoracic aortic aneurysm. A very small and unhealthy descending thoracic aorta precluded any usual repair and she underwent an ascending aortaabdominal aorta bypass graft. Histopathological features of the aorta were suggestive of aortoarteritis (Takayasu’s).     

Debatable questions in the surgical treatment of thoracic aortic aneurysms

Some controversies in the surgical approach to thoracic aortic aneurysms are discussed. The author recommends: to perform echocardiography in patients with aortic aneurysms for detection of intracardiac pathology which may complicate the postoperative course; to combine thoracic aortography with selective coronary angiography in patients with thoracic aortic aneurysm for diagnosis of coronary artery disease; to operate asymptomatic fusiform aneurysm that measure twice or more the size of the normal aorta; to resect and replace dissections of the ascending aorta during cardio-pulmonary bypass; and to use active shunts during resection of the descending and thoraco-abdominal aneurysm.     

Use of a balloon occlusion catheter for descending aortic aneurysm after total arch replacement using the elephant trunk technique

A 74-year-old man who had previously undergone prosthetic graft replacement of the total aortic arch using the elephant trunk technique and of the abdominal aorta was admitted to our hospital for surgical treatment of descending aortic aneurysm. Computed tomography (CT) on admission revealed descending aortic aneurysm of 6.5 cm in diameter, and the previously placed prosthetic graft was detected in the aneurysm. Surgery for the descending aorta was performed under femoro-femoral partial bypass. During the operation, a balloon occlusion catheter introduced through the right brachial artery into the 'elephant trunk' graft was inflated before the aneurysm was opened, then the previously placed prosthetic graft was cross-clamped and the descending aorta was replaced with a new prosthetic graft with usual fashion. The postoperative course was uneventful.     

Surgical treatment of thoracic aneurysm: a 5-year experience

The surgical results of 77 patients with an aneurysm of the thoracic or thoracoabdominal aorta who were surgically treated during a 5-year period were retrospectively evaluated. Eighty-four operations were performed. The aneurysm was located on the ascending aorta in 20 patients, on the arch in nine, and on the arch and ascending aorta in eight. Sixteen aneurysms involved the descending thoracic aorta and 27 were thoracoabdominal. Associated surgery was performed in 12 patients. Deep hypothermia and circulatory arrest were employed in 30 patients. Partial cardiopulmonary bypass was used in 15 patients. Mortality was significantly higher if operation was performed under emergency conditions: the early mortality rate was 11.7%. Aggressive surgical management of untreated aneurysm is justified, as rupture of such lesions is the most common cause of death and associated mortality is high, with a 5-year survival rate of less than 20%.