Aberrant Left Subclavian Artery Associated with a Kommerell's Diverticulum and a Left‐Sided Aortic Arch

Abstract Kommerell's diverticulum is most commonly associated with either an aberrant left subclavian artery from a right‐sided aortic arch or an aberrant right subclavian artery from a left‐sided aortic arch. We describe an exceedingly rare case of an aberrant left subclavian artery arising from a Kommerell's diverticulum in a patient with a left‐sided aortic arch, the “nonaberrant aberrant left subclavian artery.”(J Card Surg 2012;27:607‐608)     

Incomplete Isolation of the Left Innominate Artery in a Patient with Right Aortic Arch and Double Outlet Right Ventricle

Abstract Isolation of the left innominate artery (IA) with right aortic arch is a rare congenital anomaly in which the IA loses its connection to the aorta and is connected to the pulmonary artery via a left ductus arteriosus. Here, we report a case of a 9‐month‐old girl with incomplete isolation of the IA and double outlet right ventricle. Along with repair of the intracardiac anomaly, the IA was reimplanted to aortic arch to ensure adequate blood flow from the aorta. (J Card Surg 2010;25:232‐234)     

Total Aortic Arch Replacement for the Treatment of Kommerell's Diverticulum in a Jehovah's Witness

Abstract The treatment of Kommerell's diverticulum continues to evolve given advances in aortic surgery, cardiopulmonary bypass management, and endovascular techniques. This case report details the repair of a diverticulum of Kommerell in a Jehovah's witness with a right‐sided aortic arch and reviews the surgical literature . (J Card Surg 2010;25:333‐335)     

Giant Aneurysm After Aortic Coarctation: Repair without Circulatory Arrest

Abstract We describe the case of a 23‐year‐old patient presenting for redo aortic arch surgery because of recoarctation and poststenotic aneurysm formation after patch aortoplasty in infancy. Using the hemi‐clamshell approach, the entire aortic arch was replaced and the supraaortic branches were reimplanted. The applied surgical technique using hypothermic extracorporeal circulation without cardiac arrest allowed an uninterrupted cerebral and spinal cord perfusion due to stepwise clamping of the aortic arch during reconstruction and resulted in an excellent neurologic outcome at six‐month follow‐up. (J Card Surg 2010;25:560‐562)     

Transcatheter Aortic Valve Implantation with “No Touch” of the Aortic Arch for the Treatment of Severe Aortic Stenosis Associated with Complex Aortic Atherosclerosis

Abstract We present the case of an 80‐year‐old woman diagnosed with severe aortic stenosis and complex aortic atherosclerotic plaques who underwent transapical TAVI guided by transesophageal echocardiography and fluoroscopy with no catheter/wire manipulation across the aortic arch to avoid any systemic embolism. (J Card Surg 2010;25:501‐503)     

The Hybrid Stent‐Graft Technique: A Solution to Complex Aortic Problems and Lessons Learned

Abstract Objective: The frozen elephant trunk technique has been recently presented in the literature and has been considered as a novel surgical option for single‐stage repair of complex aortic pathology such as combined arch and descending thoracic aortic aneurysms. Patients and methods: The first patient, a 74‐year‐old male, was admitted severely symptomatic (interscapular pain), with aortic distal arch and proximal descending thoracic aortic aneurysm with a diameter of 6 cm. The second patient, a 72‐year‐old male, underwent descending aortic aneurysm stent grafting one year ago and was admitted gravely symptomatic (interscapular pain), with aortic arch aneurysm (diameter of 5.7cm) and type I endoleak at the proximal end of the stent. Results: The first patient developed paraplegia after the operation and died three months after the operation due to pneumonia while he was on a rehabilitation program. The second patient's recovery was uneventful and was discharged on postoperative day nine. Conclusion: This report summarizes our preliminary experience with this technique emphasizing two points: first, it offers the opportunity to manage efficiently complex aortic problems, and second, there is a potential risk of serious complications related to the limited stent sizes available of the device to match the patient's anatomical characteristics and pathology.     

Thoracic Endovascular Aortic Repair of an Aberrant Right Subclavian Artery: Technique and Long‐Term Outcome

Abstract Background: Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three‐stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long‐term clinical and radiographic follow‐up . (J Card Surg 2010;25:390‐393)     

Late Reoperations After Repair of Acute Type A Aortic Dissection

Abstract Background: Regarding surgical interventions for type A acute aortic dissection (AAD), it is currently unclear if an initial, less invasive approach followed by later reoperations is safer than an extended approach aimed at preventing future reinterventions. We retrospectively reviewed our surgical cases to clarify the safety of late reoperation after repair of acute AAD. Methods: Since 2004, 17 patients (eight female; mean age: 64.1 ± 9.3 years) of all 115 AAD cases in our institute underwent reoperations after initial repair of acute AAD, and operative factors were evaluated. Results: Anastomotic pseudoaneurysms were the main reason for reoperation; one distal, seven proximal, and two both. Seven patients required surgical reintervention because of aneurysmal dilatation of the remaining aorta. The duration between the initial and late operations was 6.4 ± 5.1 years in the anastomotic pseudoaneurysm group and 4.6 ± 4.5 years in the recurrence group. In the anastomotic pseudoaneurysm group, there were three root replacements, four resuspensions of the aortic valve, and two aortic valve replacements. Six patients required replacement of the aortic arch. Total arch replacement was the most frequent operation in the recurrence group. Three patients who required sternum reentries underwent concomitant right thoracotomies to dissect adhesions between the sternum and the aneurysm. There were no mortalities. Conclusions: Although most cases required extended procedures for late reoperation after repair of acute AAD, reoperations can be performed safely by careful choice of appropriate operative methods and strategies. Our data suggest that ascending aortic replacement is an effective initial procedure for patients with acute AAD. (J Card Surg 2010;25:208‐213)     

Hybrid Repair of Aortic Arch Aneurysm

Background: Conventional surgical repair of the aortic arch using cardiopulmonary bypass and deep hypothermic circulatory arrest still carries a substantial rate of mortality and morbidity especially myocardial injury, and predicts a high incidence of permanent neurological injury.

Endovascular stent-graft placement has been developed as an effective treatment modality in various diseases of the descending aorta. Technological improvements nowadays allow deployment in the distal arch in most instances. However, in case of total involvement of the aortic arch endovascular Sg repair, the challenge is to maintain blood flow to the brain and upper extremities, that may require covering one or more aortic branches in order to establish a secure proximal landing zone, and to ensure complete exclusion of the lesion.

The aim of this study is to report our ongoing experience with endovascular treatment of aortic arch aneurysms. Methods: During two years, 16 patients were treated with thoracic stent-grafts, after aortic arch debranching for repair of aortic arch aneurysm. All patients were at high risk for open repair and not candidates for standard endovascular repair due to inadequate proximal landing zones.

Device design and implant strategy were on the basis of evaluation of aortic morphology with spiral CT. Stent grafts were inserted to repair the arch after supra-aortic vessel transposition was performed. Follow-up was 100% complete (mean 18 ±2.5 months, range 12–24 months). Follow-up included clinical examination, chest X-ray and computed tomography at discharge, 6 months after stent-graft placement and yearly thereafter.

Results: Primary technical success rate was 100%. Patency of all endografts and conventional bypasses was 100%. No endoleak or graft migration was observed. There were no neurological complications. Surgical conversion was never required.

Conclusion: Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.     

Repair of the Aortic Arch with Fibrin Glue in Type A Aortic Dissection

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hos-pitai mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 ± 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22°C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angloscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm. These results suggest that repair of the aortic arch with fibrin glue facilitates surgery, reduces operative time, and has a lower mortality rate than aortic arch replacement. The risk of possible reoperatlon for arch replacement Is largely balanced by the good immediate and late results reported here. (J Card Surg 1994;9:734–739)     

Successful Treatment of a Gravida with Acute A Type Aortic Dissection in Late Gestation

Abstract This case report describes a woman at 35 weeks gestation, who presented with an acute type A aortic dissection involving the total aortic arch and descending aorta. She underwent a successful ascending aorta replacement, total arch replacement, and stented elephant trunk implantation at the time of cesarean section with favorable maternal and fetal outcomes . (J Card Surg 2012;27:728‐730)     

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.     

Surgical management of right aortic arch with tailored surgical approach

Abstract Background and Aim of Study: Right‐sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. Methods: We retrospectively reviewed 17 patients undergoing right‐sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. Results: Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In‐hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. Conclusion: The s urgical treatment for right‐sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention. (J Card Surg 2012;27:511‐517)     

Aortic arch aneurysms; Surgical experience

Background: Several recent modifications in technical, operative and perfusion techniques have enabled good operative results and final outcome for patients with aneurysms of the aortic arch. Although surgical procedures for this disease still remain a formidable challenge, availability of improved prosthetic grafts, myocardial protection techniques, brain protection protocols and better blood bank facilities ensure minimal postoperative morbidity and mortality. Methods: Records of 28 patients operated between January 1994 and January 2001 for aneurysms of the aortic arch were analysed. The study group includes patients with isolated aortic arch aneurysms or with concomitant involvement of the ascending and/or descending thoracic aorta. There were 22 males and 6 females, with an age range of 9–78 years. The mean age at operation was 45.5 years. Etiology included myxomatous degeneration (Marfan’s) in 10; myxomatous degeneration (NonMarfan’s) in 11; atherosclerosis in 6 and traumatic in 1 patient. Graft replacement of the transverse aortic arch with reimplantation of arch vessels was done for 6 patients; Bentall’s procedure with hemiarch replacement for 3 patients; Bentall’s procedure with arch replacement and vessel reimplantation for 4 patients; supracoronary replacement of the ascending aorta plus hemiarch repair in 2 patients; graft replacement of the distal arch alone in 11 patients and ascending, transverse and descending thoracic aorta repair using the elephant trunk technique in 2 patients. Results: Early hospital mortality was seen in 2 patients with 1 late death. Postoperative complications seen were hemorrhage requiring reoperation in 3 patients, pulmonary insufficiency in 1 patient, renal dysfunction in 1 patient, neurological morbidity in 2 patients and wound sepsis in 2 patients. Mean postoperative hospital stay was 11.4 days. Followup to the present date was completed for all survivors the range being 2–72 months (mean 29.2 months). Majority of the patients reported significant improvement in their symptoms. Conclusion: With sufficient technical skill and precautions, operative treatment for aneurysms of the aortic arch can be carried out with acceptable mortality and morbidity rates.     

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.     

Two‐Stage Total Aortic Replacement for Loeys–Dietz Syndrome

Abstract Loeys–Dietz syndrome (LDS) is a recently described connective tissue disorder characterized by generalized arterial tortuosity and aggressive aortopathy that untreated leads to early death even at aortic dimensions as small as 4 cm. We report the case of a young man with LDS successfully treated for aortic root, arch, and thoracoabdominal pathology. (J Card Surg 2010;25:223‐224)     

Hybrid Treatment for Thoracic and Thoracoabdominal Aortic Aneurysms in Patients Unfit for Open Conventional Repair

Purpose : To describe a technique combining endovascular and conventional surgery for the treatment of distal aortic arch and thoracoabdominal aortic aneurysms.

Material and methods : In the last two years, we used hybrid approach to treat six patients with distal aortic arch or thoracoabdominal aortic aneurysms unfit for open conventional repair owing poor cardio-respiratory function. Results : The primary technical success rate was 100%. Intraoperative mortality rate was 0; conversion to open conventional repair was never required. Mean operation time and blood loss averaged 256 minutes and 1233 ml, respectively. Neurological complications were not observed. Overall, two patients died postoperatively. During a mean 17-month follow-up, two minor type II endoleak occurred and were successfully managed with coil embolization. All stent-grafts and conventional bypasses were patent, and no stent-graft-related complication was observed. Conclusion : Our initial experience attests the feasibility and potential attractive alternative of hybrid treatment for distal arch and thoracoabdominal aortic aneurysms.     

Subtypes of Acute Aortic Dissection

The technique of open distal anastomosis using deep hypothermic circulatory arrest was used in 69 cases of acute type A aortic dissection. These cases were subcategorized by site of intimal tear, which was found in the ascending aorta in 41 patients (60%), in the arch in 22 patients (32%), and in the descending aorta in 5 patients (7%). Clinical characteristics and complications are described for these subtypes. Hospital mortality, which was 14.5% overall for acute type A dissections, was 14.6% for ascending tears, 18.2% for arch tears, and 0% for descending aortic tears. Six-year survival was 69%± 15% for ascending tears, 69%± 22% for arch tears, and 80%± 25% for descending tears (mean ± SEM, p = NS). A classification system for aortic dissection is proposed, based on both site of origin and propagation. (J Card Surg 1994;9:729–733)     

Aortic operation after previous coronary artery bypass grafting

Objective Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection.Methods: From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0±44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patentin-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping.Results: The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2±29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months.Conclusion: Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermie perfusion of a patentin-situ arterial graft. (Jpn J Thorac Cardiovasc Surg 2006; 54:155-159)     

Hydrodynamics of Aortic Cannulae During Extracorporeal Circulation in a Mock Aortic Arch Aneurysm Model

This study was designed to analyze flow pattern, velocity, and strain on the aortic wall of a glass aortic arch aneurysm model during the extracorporeal circulation, and to elucidate the characteristics of flow pattern in three different aortic cannulae. Different patterns of large vortices and helical flow were made by each cannula. With the curved end‐hole cannula, the high velocity flow (～0.6–0.8 m/s) was blowing to the aneurismal wall without attenuating the strain rate tensor (～0.2–0.25/s). With the dispersion cannula and the Soft‐Flow cannula, cannular jet was attenuated in the ascending aorta creating a large vortex at a velocity less than 0.5 m/s, and the strain rate tensor on the aneurismal wall was small (less than 0.15/s). In conclusion, end‐hole cannula should not be used in the operation of aortic arch aneurysm. Dispersion‐type aortic cannulae were less invasive on the aortic arch aneurismal wall, but particular attention to alternative cannulation sites should be paid in cases with severe atherosclerosis on the ascending aortic wall.