Implantation of antibiotic-releasing carriers and in situ reconstruction for treatment of mycotic aneurysm.

Four patients with mycotic aneurysm of the extracranial carotid artery, the innominate artery, the ascending aorta, and the infrarenal aorta were treated with local implantation of antibiotic-releasing carriers after resection of the aneurysm, excision of all infected tissue, and in situ reconstruction by prosthetic graft replacement in two patients and patch plasty in two patients. The patient with a mycotic aneurysm of the ascending aorta was operated on again 1 month after the first operation because of a second mycotic aneurysm located on the aortic arch. No early or late signs of recurrent infection were seen on clinical and laboratory postoperative follow-up done between 9 and 16 months or on duplex scan or computed tomography done at these times. Implantation of antibiotic-releasing carriers after débridement of all infected tissue and in situ reconstruction for treatment of mycotic aneurysm was performed successfully in four patients with this life-threatening condition.     

Antibiotic-impregnated beads for the treatment of aortic graft infection

Infection of a prosthetic graft after replacement of the ascending aorta is an uncommon but life-threatening complication of surgery. We report the use of antibiotic-impregnated calcium sulfate beads in a patient with ascending aortic graft infection to provide localized, high-dose therapy to the infected region. Perigraft placement of antibiotic beads provides an alternative method for the treatment of aortic graft infection.     

Successful treatment of ascending aortic graft infection after operation for acute aortic dissection with peripheral malperfusion

Mediastinitis with infection of an ascending aortic graft is hard to heal and is a highly fatal complication. We had a patient in whom mediastinitis with infection of such a graft as well as an ascending aorta–femoral artery bypass graft developed after the initial operation for type A aortic dissection accompanied by peripheral malperfusion. We treated it successfully by inserting a stent into the true lumen of the thoracoabdominal aorta and using a cryopreserved homograft to replace the infected ascending aortic fabric graft.     

Chronic aortic dissection (DeBakey type II) with infective thrombus in the false channel

A 68-year-old man with a DeBakey type II chronic aortic dissection developed bacteremia secondary to a urinary tract infection with the Serratia species. This resulted in an infected thrombus in the false channel and a subsequent rupture of the ascending aorta. An emergency resection of the ascending aorta and a Dacron graft interposition were performed. The patient suffered from severe neurological insufficiency and died of pneumonia 6 months postoperatively. The optimal operation time and surgical options of an infected aortic dissection should be determined.     

A Case of Graft Infection 10 Years After Ascending Aorta Replacement

A 52-year-old man was admitted with anemia and slight fever, which he had for the last 2 months. He had undergone replacement of the ascending aorta for acute aortic dissection 10 years previously. Echocardiography demonstrated a flailing thin structure in the anterior wall of the ascending aorta corresponding to the proximal portion of the prosthetic graft. This abnormal echocardiographic finding led us to repeat blood cultivation. We finally detected Enterococcus facium and Staphilococcus epidermidis in his blood sample. We diagnosed this as a graft infection and prepared for surgical re-replacement of the infected graft. While he was waiting for the operation, an infectious aneurysm of a tibialis posterior artery ruptured and an emergency operation was done. Replacement of the infected ascending aorta graft was done thereafter. In surgery, 2-cm-long vegetation was found. It stuck to the graft wall near the former hole used for air removal in the first surgery. The patient recovered fully and left our hospital after 3 months of postoperative antibiotics therapy. This rare case of aortic graft infection long after the original replacement surgery suggests the importance of thorough echocardiographic investigation of prosthetic graft infection as a possible cause of fever of unknown origin.     

Management of a case of infected thoracic aorta prosthesis with creation of extra anatomic conduit from ascending aorta to bilateral femoral arteries

The management and treatment of an infected aortic aneurysm is a tricky one and is usually done by graft excision and creation of an extra anatomic conduit. We present here a case of a 53 year old patient who underwent a prosthetic graft insertion for leaking thoracic aortic ulcer with esophageal compression. Post operatively, the thoracic wound got infected and he developed esophageal leak for which a de-functioning esophagectomy had to be done. Later, the patient had bleeding from thoracic cavity and developed cardiovascular collapse. He was managed successfully by creation of an extra anatomic conduit from ascending aorta to bilateral femoral arteries followed by excision of the original prosthetic graft.     

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.     

Successful treatment of an infected thoracic endovascular stent graft

A 70-year-old man with a chronic type B aortic dissection was treated with two stent grafts deployed in the descending thoracic aorta. The patient was re-admitted to the hospital at 16 months after thoracic endovascular stent grafting because of a high fever. A blood culture showed sepsis due to a Staphylococcus species. A CT scan showed an increase in the size of the thrombosed false lumen. Complete excision of the infected descending aortic wall and infected stent graft were performed. The descending thoracic aorta was reconstructed using a rifampicin-bonded Dacron graft and omental wrapping. The combination of in situ graft replacement using a rifampicin-bonded graft and omental wrapping is considered an effective treatment for thoracic stent graft infection.     

A型主动脉夹层动脉瘤的外科治疗

目的　总结 1996年 1月至 2 0 0 2年 8月收治的 34例 A型主动脉夹层动脉瘤的外科治疗经验。　方法　应用 Bentall手术 19例 ,升主动脉人工血管置换术 7例 ,升主动脉人工血管置换加主动脉瓣成形术 (Trusler's法 )5例 ,分别行升主动脉人工血管置换及主动脉瓣置换术 (Wheat术 ) 2例 ,升主动脉、主动脉弓人工血管置换术 1例。结果　手术死亡 6例 ,死亡率 17.6 %。其中慢性主动脉夹层动脉瘤死亡 3例 ,急性夹层动脉瘤死亡 3例。随访 2 0例 ,随访率 71.4 %。随访时间 2～ 4 6个月 ,平均 2 4 .7个月 ,1例术后 3个月猝死 (原因不明 ) ,1例术后 6个月死于心内膜炎。18例存活患者情况良好。　结论　应根据夹层动脉瘤的部位及范围采用不同的手术方式 ,保留主动脉瓣的升主动脉人工血管置换术治疗该病效果较好 ,准确可靠的吻合技术、保留瘤壁的完整性 ,将使手术更为安全。     

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.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.     

Mid-term results of aortoplasty for dilated ascending aorta associated with aortic valve disease.

BACKGROUNDS: Dilatation of the ascending aorta concomitant with aortic valve disease is occasionally associated with progressive enlargement of the ascending aorta or acute aortic dissection (AAD). However, surgical procedure of choice for the aorta and its indication are controversial. PATIENTS AND METHODS: From July 1995 to August 2001, 10 patients with a moderately dilated ascending aorta (mean diameter, 52+/-4.8 mm) underwent concurrent aortic valve replacement (AVR) and aortoplasty. The aortic valve was bicuspid in eight patients. To tailor the ascending aorta 30-35 mm in diameter, the aortic wall was partially resected along the aortotomy, and the aorta was directly closed. RESULTS: Operation time and most of other perioperative variables were comparable to those of patients who underwent isolated AVR. The aortic diameter was reduced to 36.1+/-4.1 mm. Nine patients survived to hospital discharge uneventfully, but one patient developed disruption of the suture line in the aorta and died. During follow-up, no patient suffered AAD but redilatation was observed in one patient. In the two problematic patients, the ascending aorta was larger than 55 mm, and its media was histologically abnormal. CONCLUSION: In patients with dilated ascending aorta less than 55 mm in diameter, aortoplasty can be a procedure of choice. However, a prosthetic graft replacement is recommended when the diameter of the ascending aorta is larger than 55 mm.     

Postoperative mediastinitis following hemiarch replacement

Although various strategies have been advocated for mediastinitis following cardiac operations, surgical results for this complication remain a significant concern. The condition would be more complicated with replacement of the ascending aorta using a prosthetic graft. We present the case of a 50-year-old female patient with acute aortic dissection who underwent hemiarch replacement using a prosthetic graft and concomitant coronary artery bypass grafting, and developed periprosthetic purulent collection 2 months later. Successful treatment involved debridement of infected tissues and omental flap transposition. Postoperative chest computed tomography revealed no sign of perigraft infection. Omental flap transposition can be effective for treating mediastinitis following prosthetic graft replacement of the ascending aorta. The patient has remained in good health for 1 year, with no signs of recurrent graft infection or pseudoaneurysm formation.     

Composite vein graft reconstruction for infected descending aortic prosthesis

We report a case of successful in situ replacement with a superficial femoropopliteal vein panel graft for Dacron graft infection of the thoracic aorta. A 75-year-old man presented with septicemia and pseudoaneurysm caused by methicillin resistant staphylococcus aureus 2 years after Dacron graft replacement of the mid-descending aortic aneurysm. The patient underwent in situ replacement with a panel graft constructed of 3 deep vein panels after excision of the infected Dacron graft. The patient is free of infection and doing well over 2 years after surgery.     

A novel technique of coronary revascularization in porcelain aorta: Report of two cases

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.     

A case of graft replacement of the ascending aorta to the aortic arch and the partial descending aorta in a single stage for thrombosed aortic dissection (debakey type II + IIIB)

We report here a case of graft replacement of the ascending aorta to the aortic arch and the middle portion of the descending aorta in a single stage for thrombosed aortic dissection. The patient was a 53-year-old male who was transfered to our hospital with a diagnosis of thrombosed aortic dissection. Conservative therapy was continued but three weeks after the onset, chest enhanced CT scan and digital subtraction angiography revealed an opacified false lumen in the ascending aorta and a ulcer like projection in the middle portion of the descending aorta. He was therefore diagnosed as having redissection in DeBakey type II + IIIb thrombosed aortic dissec- tion. Graft replacement of the ascending aorta, the aortic arch, and a part of the descending aorta was performed in a single stage via median stenotomy with the aid of extracorporeal circulation and selective cerebral perfusion. Postoperative digital subtraction angiography showd satisfac- tory reconstruction of the thoracic aorta. The patient is still leading a normal life two years after the operation.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

Tubular supravalvar aortic stenosis: replacement of ascending aorta in a young patient

The diffuse form of supravalvar aortic stenosis represents a surgical challenge when ascending aorta and proximal aortic arch are involved. We describe a technique performed on a 14-year-old patient with normal aortic annulus and severe diffuse supravalvar aortic stenosis in which the replacement of ascending aorta and proximal aortic arch with a tubular prosthetic graft completely relieved the obstruction as confirmed by cardiac catheterization.     

Rupture of ascending aorta secondary to tuberculous aortitis

Tuberculous aortitis generally develops at the distal aortic arch and the descending aorta that are close to specific groups of mediastinal lymph nodes, but exceptionally it develops in the ascending aorta. We report a case of rupture of the ascending aorta after tuberculous aortitis in a 53-year-old man without a history of tuberculosis or evidence of a primary foci who underwent cardiopulmonary resuscitation due to severe hemoptysis with subsequent cardiac arrest. The tuberculous aortitis associated with rupture of the ascending aorta was treated with surgical resection and in situ graft placement.     

Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic valve endocarditis

BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement. METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%. RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 +/- 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation. CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.