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.     

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.     

Traumatic avulsion of the innominate and left carotid arteries: successful repair

Traumatic rupture of the aorta or the arch vessels is a rare and frequently fatal injury. This lesion should be considered in all cases of severe chest trauma. Early aortography is essential for accurate diagnosis. Nineteen cases of avulsion of the innominate artery have been previously reported. In only two of them a second aortic arch branch had an associated injury. The case presented here is the first successful repair of a combined avulsion of both the innominate and the carotid arteries from the aortic arch. Cerebral circulation was maintained during the operation with a heparin-coated shunt from the ascending aorta to the right common carotid artery. Reconstruction was accomplished by inserting a bifurcated Dacron prosthesis from the aorta to the innominate and left carotid arteries. The use of a heparin-bonded shunt maintained cerebral perfusion, and greatly simplified the operation and avoided the risk of extracorporeal circulation and systemic anticoagulation in a patient with multiple trauma.     

Surgical treatment of a retrosternal pseudoaneurysm arising from the posterior aortic root

We report a case of a 60-year-old male with a retrosternal pseudoaneurysm arising from the posterior aortic root. He had undergone replacement of the aortic root and ascending aorta for an acute aortic dissection. His postoperative course was complicated with composite graft infection. During a redo surgery, femoro-femoral bypass was established prior to sternotomy via the right femoral artery and vein, and ten French cannulas were directly inserted into both carotid arteries through separate skin incisions for brain perfusion. When the sternum was divided, an occlusion balloon catheter introduced through the left femoral artery was inflated to maintain somatic perfusion without compromising clear vision of the operative field. Combined procedures with direct cannulation into both common carotid arteries and balloon occlusion of the distal aortic arch allowed us to safely perform replacement of the aortic root and ascending aorta in the patient with a retrosternal pseudoaneurysm.     

Anomalous Origins of the right vertebral, subclavian, and common carotid arteries in a patient with a four-vessel aortic arch

Many anomalies of the aortic arch and great vessels are uncovered as serendipitous findings on imaging studies, in the anatomy laboratory, or at surgery. A 56-year-old man had an arch angiogram as part of an evaluation for cerebrovascular disease. A four-vessel left aortic arch was identified consisting of the right carotid, left carotid, right subclavian, and left subclavian arteries. The right common carotid gave rise to the right vertebral artery in the chest while the normally located left vertebral arose from the left subclavian artery. No aneurysm or aortic diverticulum was identified.     

Brachiocephalic arterial aplasia of the right aortic arch with subclavian steal syndrome

A 44-year-old man was admitted to our hospital with complaint of weakness in his left upper extremity, vertigo, and diplopia. After aortic root injection of contrast medium, a right aortic arch was visualized. The left brachiocephalic artery was not found, however. An operation was performed through a midline sternotomy. The first branch of the aortic arch was the right common carotid artery, and the second branch was the right subclavian artery. The left brachiocephalic arterial aplasia was recognized. An E-PTFE graft was anastomosed proximally to the ascending aorta and distally to the junction of the left common carotid and left subclavian arteries. After the operation, some of the symptoms were improved and the others were removed.     

累及弓部主动脉夹层手术方式选择及疗效

目的:探讨累及主动脉弓部主动脉夹层手术方式选择及疗效。方法:收集2010年2月—2015年5月因主动脉弓部夹层在广州军区武汉总医院心胸外科接受手术治疗病例资料,分析其手术方式选择及理由,不同术式并发症发生率等。结果:检索出符合条件的病例92例,其中仅行胸主动脉腔内修复术(TEVAR)36例,预开窗血管支架的TEVAR 2例,封闭左锁骨下动脉的TEVAR 31例,不开胸主动脉弓分支血管旁路术+TEVAR17例(左颈总动脉-左锁骨下动脉旁路术4例,右颈总动脉-左颈总动脉-左锁骨下动脉旁路术3例,右颈总动脉-左颈总动脉术、封闭左锁骨下动脉10例),开胸主动脉弓置换术6例。2例开胸主动脉弓置换术患者术后死亡,其余术后无严重并发症发生。结论:对于累及主动脉弓部夹层,开胸主动脉弓置换术是一种成熟的治疗方式;TEVAR是的一种快速、有效、经济、术后并发症少的手术方式,并可以通过开窗、分支血管旁路术等方式扩大其应用范围。     

Total arch replacement through re-median sternotomy after coronary surgery

We report the case of 78-year-old-man who required graft replacement of an aortic arch aneurysm. He previously had undergone off-pump coronary artery bypass grafting with the right internal thoracic artery bypassed to the left anterior descending artery. For this difficult case, we successfully performed total arch replacement using selective antegrade cerebral perfusion through a re-median sternotomy without injuring the right internal thoracic artery, which was the only blood source for the left and right coronary arteries.     

Hybrid treatment of a ruptured aneurysm in the distal aortic arch: report of a case

An 80-year-old man was transferred to our hospital for surgical treatment of a ruptured aortic arch aneurysm. Based on a history of severe heart failure and coronary artery bypass, we considered him unsuitable for conventional open repair. He underwent a hybrid repair, in the form of supra-aortic vessel debranching followed by endoluminal aortic repair. Although the ostia of the left carotid and left subclavian arteries were occluded by the stent-graft, the left supra-aortic vessels and the left internal thoracic artery attached to the coronary artery were perfused through an extra-anatomic bypass from the right axillary artery to the left carotid artery and the left axillary artery. After additional endovascular repair for recurrent hemosputum, the patient recovered without complications. Although continued follow-up is necessary, acute hybrid arch repair seems feasible for treating ruptured aortic arch aneurysms, even in the setting of severe heart failure and a previous coronary artery bypass.     

Repair of coarctation with persistent fifth arterial arch and atresia of the fourth aortic arch

Coarctation of the aorta with persistent fifth arterial arch and atresia of the fourth aortic arch between the left common carotid and left subclavian arteries was treated surgically in a two-month-old boy with transposition of the great arteries and double-outlet right ventricle. The aortic arch was repaired using side-to-side anastomosis of the left common carotid and left subclavian arteries, patch repair of the coarctated segment at the origin of the left subclavian artery, and ligation of the patent ductus arteriosus. Pulmonary arterial banding and balloon atrioseptostomy were performed for associated anomalies.     

Hypoplastic circumflex retroesophageal right-sided cervical aortic arch with unusual vascular arrangement and severe coarctation

We report the case of a 12-year-old boy with a hypoplastic retroesophageal circumflex right-sided cervical aortic arch and coarctation. After the incidental finding of a heart murmur when the boy was 9 years old, cardiac magnetic resonance showed a right-sided cervical aortic arch, hypoplastic transverse arch, and separate origin of the left common carotid, right common carotid, right vertebral, and right subclavian arteries. The left subclavian artery arose from the proximal descending aorta next to the coarctation. An extra-anatomical ascending to descending aorta tube graft was inserted through a right lateral thoracotomy with good results.     

Common trunks of the subclavian and the vertebral arteries: presentation of a new aortic arch anomaly

Information about the variations of the origins of subclavian and vertebral arteries and their course is of great importance for head and neck surgery. The normal vertebral arteries arise as the first branches of the corresponding subclavian arteries. In a minority of cases, the left vertebral artery could arise directly from the aortic arch between the left common carotid and the left subclavian arteries. An aberrant right subclavian artery arising as the last branch of the aortic arch is also a frequently seen aortic arch anomaly. Here, we present a case with common trunks of the subclavian and vertebral arteries, demonstrated by cardiac catheterization.     

Use of the Gott shunt in the prosthetic replacement of the aortic arch]

Our previous experience in 272 consecutive cases of descending thoracic aortic aneurysms resected without paraplegia by using the 9 mm Gott shunt encouraged us to apply the same technique to more complex aortic surgery. Graft replacement of the transverse aortic arch with brachio-cephalic vessel reattachment was undertaken in 2 patients without the aid of extracorporeal circulation and without systemic heparinisation. Body perfusion was achieved with two 9 mm Gott shunts inserted between the ascending aorta and both femoral arteries. A 10 mm graft interposition between the shunts and the femoral arteries allowed for retrograde perfusion and distal leg irrigation. Blood supply to the brain was maintained with the cut halves of a 7 mm Gott shunt connected as side branches to one of the 9 mm shunts, allowing cannulation of the innominate ant the left carotid arteries. In 90 of the 272 patients treated for a descending aortic aneurysm, a mean shunt flow of 2526 ml/min. was recorded through the 9 mm Gott shunt and from there, we took for granted that the total cardiac output, in there 2 patients, could be propelled by using 2 shunts. During aortic cross clamping, there were no change in the filling pressure of either the right heart or the left heart, and no metabolic acidosis was observed. Both patients survived with normal physiological function of all organs including the brain and the spinal cord.     

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.     

Aortic reconstruction after complex injury of the mid-transverse arch

We report the case of a 28-year-old man who suffered a transection of the mid-transverse aortic arch between the innominate and left common carotid artery with complete avulsion of the left common carotid artery after blunt trauma. This patient underwent successful aortic arch replacement proximal to the left subclavian artery and reimplantation of the innominate and left carotid arteries using profound hypothermic circulatory arrest and selective antegrade cerebral perfusion. A literature review revealed no other previous reports of survival after this type of injury.     

Successful resection of an aortic arch aneurysm using a temporary trifurcation bypass graft

Resection of a syphilitic aortic arch aneurysm in a 62-yearold woman was accomplished using a trifurcation temporary bypass system. The bifurcation graft was sutured end-to-side to the ascending thoracic aorta, to the brachiocephalic trunk and to the left common carotid artery, respectively. The attached third limb end was anastomosed end-to-side to the infrarenal abdominal aorta. This technique enabled a larger shunt into the abdominal aorta. Occlusion of the iliac arteries proved to be effective in coping with hypotension while attending to the bypass and the volume replacement. The post-operative recovery was uneventful and the patient has remained well after 43 months.     

Total replacement of the transverse aortic arch with the Gott aneurysm shunt

A new method of temporary external shunting for total replacement of the aortic arch is described. Its greatest advantage is that systemic heparinization is not required. In a 46-year-old man total body perfusion was achieved with two 9-mm Gott aneurysm shunts inserted between the ascending aorta and both femoral arteries. Blood supply to the brain was maintained with the cut halves of a 7-mm Gott shunt connected as side branches to one of the 9-mm shunts, allowing cannulation of both carotid arteries. The total cardiac output, measured at 4.7 L/min by the thermodilution technique through a Swan-Ganz catheter, was propelled through these preheparinized multibranch shunts. A flowmeter adapted on one of the 9-mm Gott shunts demonstrated a shunt flow of 2000 ml/min and it was deduced that the other 2700 ml of the total cardiac output was delivered by the other shunt. During the 29 minutes of cross-clamping, there was no change in the filling pressure of either the right heart (central venous pressure 5 cm H2O) or the left heart (pulmonary wedge pressure 8 mm Hg). Aortic continuity was reestablished with the interposition of a 34-mm tubular woven Dacron prosthesis, on which two 10-mm woven Dacron side branches were anastomosed to the innominate and left common carotid arteries. The patient had no neurologic deficit and had normal physiologic function of all other organs.     

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: preliminary experience in 26 patients

BACKGROUND: In aortic operations performed through a left thoracotomy, which require total bypass and deep hypothermic circulatory arrest, femoral artery cannulation is commonly used for arterial perfusion. This route limits the time of safe circulatory arrest and is associated with the risks of retrograde embolization or, in the case of aortic dissection, malperfusion of the vital organs. To overcome these problems, we have used cannulation of the extrathoracic left common carotid artery to ensure a central a route of arterial perfusion in these operations. The preliminary results are presented. METHODS: Between December 1999 and April 2001, we used left common carotid artery cannulation in 26 operations on the thoracic aorta performed through a posterolateral thoracotomy with an open technique during deep hypothermic circulatory arrest. Institutional review board approval and informed consent were obtained. The indications included perforating atherosclerotic ulcer (n = 5), chronic aortic aneurysm (n = 9), acute type B aortic dissection (n = 3), and chronic dissection of the thoracic aorta (n = 9). Transcranial Doppler ultrasonographic monitoring of both the right and left middle cerebral arteries was used to assess the adequacy of cerebral bihemispheric perfusion and to determine the differences in blood flow velocities throughout the procedure. RESULTS: Left common carotid artery cannulation was successful in all patients. All patients awoke from the operation, and none had cerebrovascular accidents. None died in the hospital, and complications related to carotid artery cannulation were not observed. None of the patients experienced postoperative paraplegia. In all patients transcranial Doppler monitoring indicated the absence of cerebral embolic phenomena throughout the entire procedure. Significant differences in middle cerebral artery flow velocities were observed at different phases of the procedures and between the right and left middle cerebral arteries during carotid cannulation and during selective cerebral perfusion. Nevertheless, the maximal drop of right middle cerebral artery blood velocity during selective perfusion through the left common carotid artery was within 50% of the left middle cerebral artery velocity, indicating adequate bihemispheric perfusion. CONCLUSIONS: In patients undergoing aortic operations through a left thoracotomy, extrathoracic left common carotid artery cannulation was a safe and effective means of providing proximal arterial inflow during cardiopulmonary bypass, which can be used to selectively perfuse the brain, as well as to prevent embolic phenomena in the arch vessels.     

Retrograde Air Embolization during Routine Radial Artery Catheter Flushing in Adult Cardiac Surgical Patients: An Ultrasound Study

Background: Rapid flushing of radial artery catheters may result in retrograde embolization of air into the cerebral circulation. This study examined the incidence of central air embolization during and after flushing of an arterial pressure monitoring system.

Methods: One hundred adult patients undergoing cardiac surgical procedures were enrolled in this study. Ten ml of saline and blood were withdrawn into a syringe in the arterial flushing-sampling pressure system and then readministered to the patient through a 20-gauge radial artery catheter over 3-12 s. The right carotid artery, left carotid artery, and aortic arch were visualized using ultrasound imaging techniques during three manual flushes of the system. The left and right common carotid arteries were examined for the presence of macrobubbles or microbubbles using a linear array ultrasound transducer. The aortic arch was imaged using transesophageal echocardiography to detect retrograde air emboli. The severity of air embolization was quantified using a modification of an established grading system.

Results: A total of 298 ultrasound studies in 100 patients were recorded and analyzed after radial artery catheter flushing. Two aortic arch images were not obtained because of an inability to place the probe. Most clinicians (54%) returned flush solution to patients at near-maximal injection rates (2-3 ml per second). No air emboli (macrobubbles or microbubbles) were detected in the carotid arteries or aortic arch of any subject.