Surgical treatment for thoracic aortic aneurysm with aberrant right subclavian artery

We present two operative cases of thoracic aortic aneurysm combined with aberrant right subclavian artery (ARSA). Case 1 was a 71-year-old man with a fusiform-type arch aneurysm. He underwent total aortic arch replacement to reconstruct all 4 arch branches. Case 2 was a 39-year-old man suffering from chronic DeBakey type IIIb dissection. He underwent total descending thoracic aortic replacement for the remaining ARSA. In both cases ARSA was diagnosed preoperatively by reconstructed three-dimensional computed tomography (3D-CT). Both patients followed uneventful postoperative courses with excellent results. 3D-CT is helpful for precise planning of surgical strategy in such cases.     

Preferable surgical approaches to the aortic root-arch in patients with functioning tracheostomy

Preferable surgical approaches to aortic diseases occurring between the aortic root and the arch in patients with functioning tracheotomy or permanent tracheostomy are described for securing adequate exposure and avoiding postoperative mediastinitis. Case 1: A 41-year-old man with Marfan syndrome presented with chronic type A thrombosed aortic dissection and severe aortic valve regurgitation. He had had a functional tracheostomy for managing respiratory function due to traumatic spinal cord damage. The heart and the ascending aorta were shifted to the right side of the chest and showed a significant counterclockwise rotation. Therefore, the reverse L-figure approach of a right-sided 3rd intercostal anterior thoracostomy and lower midline sternotomy was performed for Bentall operation. Case 2: A 76-year-old woman presented with thoracic aortic aneurysm of 11 cm in diameter. She had had a permanent tracheostomy with total laryngectomy. Therefore, cram shell approach was performed for total arch replacement. The 2 cases had no postoperative mediastinitis. These approaches are recommended for aortic diseases occurring in the ascending aorta or the aortic arch in patients with functioning tracheotomy.     

Two cases of stent graft repair for thoracic aortic dissection: usefulness of three-dimensional computed tomogram]

We carried out stent graft repair in two patients with Stanford type B thoracic aortic dissection. A 51-year-old male was admitted to our hospital because of thoracic aortic dissection. Chest CT revealed an aneurysm of the distal aortic arch. The entry was pointed out 1 cm distal from the take off of the left subclavian artery in three-dimensional CT (3 D-CT). He was treated with a Gianturco stent which was anchored into the 30 mm Hemashield graft under selective cerebral perfusion. Another case was a 72-year-old male with a descending aortic aneurysm. 3 D-CT showed that the entry existed 4 cm proximal to the celiac artery. We performed transluminal implantation of the spiral Z-stent covered with the woven Dacron graft. 3 D-CT was useful for the preoperative management and the surgical treatment of thoracic aortic dissection.     

One advice to the decision of graft size for ascending and total arch graft replacement (in a case of differential diameters in ascending aorta and descending aorta)

We carried out the surgery of thoracic aortic aneurysm in fifty-eight patients from June 1994 to February 1999 (including aortic dissection in twenty-six patients). The mean size of grafts were 28.1 mm in ascending graft replacement, 25.8 mm in both ascending and arch graft replacement and 23.8 mm in descending graft replacement. The grafts for ascending aortic aneurysm were significantly larger than those for descending aortic aneurysm. In two of twenty-six patients undergoing both ascending and arch graft replacement, different size of grafts were used for ascending replacement and for arch replacement with satisfactory results in terms of bleeding from the anastomotic sites. Case 1; A 45-year-female with aortitis syndrome and aortic regurgitation due to annuloaorticectasia and thoracic aortic aneurysm underwent simultaneous aortic root replacement with composite graft (25 mm St. Jude Medical valve and 28 mm Hemashield graft) and total arch replacement (30 mm Hemashield graft with two side branches). Case 2; A 64-year-female was diagnosed as chronic type II dissecting aneurysm combined with acute type I aortic dissection. Ascending aorta was replaced with a 26 mm Hemashield graft, and the aortic arch was replaced with a 24 mm Hemashield graft with three side branches.     

Microembolization from an abdominal aortic aneurysm after thoracic aortic replacement.

A 66-year-old man with thoracic and abdominal aortic aneurysm suffered from microembolism in the lower extremities after total arch replacement. He presented with livedo reticularis with palpable peripheral pulses, and the serum creatinine kinase level elevated up to 7,695. The abdominal aortic aneurysm, but not the thoracic aorta, was the origin of this complication. The morphological change of thrombus in the abdominal aorta detected by ultrasonography was the key to the diagnosis. Graft replacement of the abdominal aorta finally resolved his problem.     

Total arch replacement of late aneurysm after bypass grafting for coarctation of the aorta.

We present the case of a 53-year-old man who underwent a total arch replacement for descending thoracic aortic aneurysm of distal anastomosis site after bypass grafting for coarctation of the aorta at 26 years of age.     

Three-dimensional demonstration of the spinal cord artery with 64-row computed tomography

This is a report of 2 cases, in which preoperative 3-dimentional demonstration of the spinal cord artery with 64-row computed tomography was feasible, less invasive, less time-consuming, and helpful in making an interventional strategy for complex aortic disease, resulting in no postoperative paraplegia One was a 63-year-old man, who underwent total arch replacement and a long elephant trunk method for arch and descending aortic aneurysms. The length of the long elephant trunk was so determined that it ended between the descending aortic aneurysm and the origin of the spinal cord artery. The second case was a 59-year-old man, who underwent descending thoracic aorta replacement for type B aortic dissection. During the distal anastomosis, the dissection septa were trimmed in order to perfuse the blood into the true and 2 false channels, one of which was connected to the spinal cord artery. In this report, we are not suggesting that preservation of the demonstrated spinal cord artery is enough for spinal cord protection, because it is still controversial. Further study is needed to confirm the reliability and reproducibility of our methods.     

Complex Thoracic Aortic Aneurysm: A Combined Open and Endovascular Approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

A case report of surgical treatment of acute aortic dissection (DeBakey III B) in association with thoracic aortic aneurysm]

This is a case report of 63-year-old man suffering from DeBakey III B acute dissection in association with thoracic aortic aneurysm. He had been following up for hypertension and thoracic aortic aneurysm. He was brought to the hospital by city ambulance complaining of sudden onset of severe back pain. Emergency operation was carried out. It revealed aneurysm of 90 mm in diameter located just distal to the aortic arch and an intimal tear or entry of the dissection located distal to the left subclavian artery. A low porosity Dacron graft was interposed between the distal aortic arch and middle portion of the thoracic descending aorta using inclusion technique. Systemic circulation was bypassing external iliac vein to artery using pump-oxygenator during aortic clamping. His postoperative course was uneventful. In review of the literature, association of the atherosclerotic aneurysm and acute dissection occurred approximately 5% in the cases of aortic dissection with increasing risk of aneurysmal rupture.     

Left pulmonary artery occlusion due to compression by aortic aneurysm

A 72-year-old man with shock was transferred to our emergency room. The computed tomograms revealed a ruptured giant thoracic aortic aneurysm obstructing the left pulmonary artery. Emergency total aortic arch replacement was performed, and the postoperative course was uneventful. The postoperative angiography confirmed the total occlusion in the left pulmonary artery which was due to compression by the aortic aneurysm.     

Two-staged hybrid surgery for an extended thoracic aortic aneurysm with Komerell's diverticulum

We have successfully performed 2 staged hybrid operation for an extended thoracic aortic aneurysm with Komerell diverticulum, which lessened surgical stress of the patient with avoidance of postoperative complications. An 82-year-old man who had been under observation for thoracic aortic aneurysm was admitted to the hospital with continuous chest discomfort. The patient initially underwent graft replacement for an ascending and arch aneurysm by using the elephant trunk technique. Thirty-five days later, he underwent endovascular repair for the residual descending thoracic aneurysm. The postoperative course was uneventful, and postoperative computed tomography (CT) revealed no stent migration and just a little type II endoleak. This 2 staged hybrid approach might be less invasive than the conventional approach, and be a potential therapeutic option for high risk patients with an extended thoracic aortic aneurysm.     

Surgical treatment of aortic arch aneurysm associated with the aberrant right subclavian artery

A 64-year-old man, who had an aneurysm of aortic arch associated with the aberrant right subclavian artery, was treated successfully. He was pointed out to have an aneurysm of aortic arch three years ago. Three years later angiograms and computed tomography revealed that it became larger compared with the initial finding. He underwent a replacement of the aortic arch using a woven Dacron graft under open distal method. Aberrant subclavian artery was not involved in the aneurysm. But because the left subclavian artery was involved in it, a woven Dacron graft was interposed between the ascending aorta and left subclavian artery. Postoperative course was uneventful and there were no complications.     

Gleichzeitige Durchführung von Debranching und endovaskulärer Versorgung eines rupturierten Aortenaneurysmas bei aberrierender A. subclavia rechts

A 62-year-old female patient with a known aberrant right subclavian artery (ARSA) and previous endovascular repair of Stanford type-B aortic dissection presented for follow-up. CT revealed a contained rupture of the proximal descending aorta with a maximum diameter of 80 mm involving the aortic arch and the origin of the ARSA. Combined debranching of the supra-aortic vessels via median sternotomy and endovascular obliteration of the thoracic aortic aneurysm was performed. The aberrant ARSA was ligated. Postoperative imaging showed excellent results without endoleak. The postoperative course confirmed tolerance of ARSA ligation. A hybrid approach to the proximal descending aorta is favorable even in cases of aberrant right subclavian artery. A team approach and appropriate planning is essential for success. The English full-text version is available at SpringerLink (under“Suppplemental”).     

Aberrant right subclavian artery re-routing for hybrid repair of proximal descending aortic aneurysm

Background

An aberrant right subclavian artery (ARSA) is a relatively prevalent vascular anomaly. What is the most appropriate treatment for thoracic aortic aneurysm combined a non-aneurysmal change ARSA?

Case presentation

A 52-year-old man was admitted to our institute due to a history of chronic cough, dysphagia and an abnormal chest radiographic finding. Because of his progressive symptoms and large fusiform thoracic aneurysm, we performed the hybrid repair for simultaneous relief of an ARSA causing dysphagia and thoracic aneurysm.

Conclusion

In case without aneurysm of ARSA, especially in conjunction with approximate thoracic aneurysm, our approach is suitable because the revascularization using the right carotid to subclavian artery re-routing prior to endograft deployment is justified in order to preserve circulation of posterior brain, spinal cord, internal mammary artery and upper limb and to prevent large retrograde type II endoleaks, as well as simplicity and durability.

     

Total aortic arch replacement for a patient with poor left ventricular function and patent coronary artery bypass grafts: how to establish effective myocardial protection

A 66-year-old man who had previously undergone coronary artery bypass grafting (CABG) was admitted to our institution for surgical treatment of a ruptured aortic arch aneurysm. He had three patent bypassed grafts including the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), complicated by left ventricular dysfunction. Coronary angiography performed 1 year after the initial surgery revealed total occlusion of the LAD. In addition, the aneurysm was located next to the LITA; therefore, there was a significant risk of injury to the LITA during intraoperative dissection. For such a complicated and challenging case, we successfully performed a total aortic arch replacement using a Y-shaped composite saphenous vein graft (SVG) for the administration of cardioplegic solution to establish effective myocardial protection. This procedure, by which effective myocardial protection can be achieved, is a useful treatment option for aortic arch surgery after CABG with a patent LITA graft.     

A case report of total aortic reconstruction and choice of staged operation in Marfan syndrome]

A 37-year-old man with Marfan syndrome underwent four operations for extensive cardiovascular disease. He was diagnosed as having AAE, AR and DeBakey type I aortic dissection. First, Bentall operation using Piehler procedure and total aortic arch replacement using retrograde cerebral perfusion and profound hypothermia at 18 degrees C were performed on May 11, 1994. Second, repair of leakage of the right coronary artery anastomosis and grafting for the descending thoracic aortic aneurysm were performed on December 3, 1994. Y-type grafting for the AAA was performed on December 21, 1996. Last, grafting for TAAA was performed under hypothermia at a rectal temperature of 20 degrees C on November 17, 1997. This surgical strategy of staged operation for extensive cardiovascular disease in Marfan syndrome is an effective method. Regular follow-up by CT is necessary for deciding the time and method of reoperation.     

Combined valve-sparing root replacement and total arch replacement with frozen elephant trunk

We report a case of simultaneous repair of an extensive thoracic aortic aneurysm from the aortic root to the distal aortic arch. A 54-year-old male had annuloaortic ectasia and a transverse aortic and distal arch aneurysm. Aneurysms of the descending aorta and the abdominal aorta were also demonstrated. The patient underwent aortic valve-sparing root reconstruction, replacement of the aortic arch and placement of a frozen elephant trunk stent-graft concomitantly through a median sternotomy incision. Because a complicated procedure was necessary, root reconstruction was performed first and coronary perfusion was resumed. This case suggests that the surgical procedure should be determined on the bases of the situation of thoracic aortic aneurysm and the general condition of the patient. Treatment for extensive diseased aorta from the aortic root to the distal aortic arch is a surgical challenge. Although single-stage repair is one of the options for this condition, it is very invasive. Total arch replacement with the frozen elephant trunk technique is efficacious to exclude distal arch aneurysm or descending aortic aneurysm through median sternotomy. An aortic valve-sparing operation was developed to preserve the native aortic valve function in order to improve the patient's quality of life. We herein report a case of concomitant total arch replacement using a frozen elephant trunk and aortic valve-sparing operation for extensive thoracic aortic aneurysm.     

Endovascular repair of thoracic aortic aneurysm associated with right-sided aortic arch: report of two cases

Right-sided aortic arch (RAA) is a rare congenital disorder. We describe herein two cases of thoracic aortic aneurysm with a right aortic arch and right-sided descending aorta treated with thoracic endovascular aortic repair (TEVAR). In one case, a 70-year-old man with Edwards type 1 RAA underwent TEVAR using a Relay stent-graft (Bolton Medical, Barcelona, Spain). In another case, a 72-year-old woman with Edwards type 3 RAA underwent TEVAR using a Kawasumi Najuta stent-graft (Kawasumi Laboratories, Inc., Tokyo, Japan) with the “buffalo horn chimney technique”, our original method for left subclavian artery flow preservation. The postoperative courses were uneventful. Postoperative computed tomography showed complete exclusion of the aneurysm without endoleakage. Compared to conventional open surgical repair, TEVAR is challenging in patients with a RAA and right-sided descending aorta. However, our results showed that TEVAR might be feasible and a treatment option even in a patient with a RAA and right-sided descending aorta.     

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.