Hypothermia and circulatory arrest in reconstruction of aortic arch. A report of nine cases

From 1982 until October 1985 we operated 9 cases of aortic aneurysm involving the transverse aortic arch (5 male and 4 female, from 26 to 69 years). Two patients had an acute dissecting aortic aneurysm, the others had an aneurysm of the aortic arch involving also the ascending aorta in 5 cases and the descending aorta in 1. Three patients underwent aortic valve replacement and implantation of coronary orifices. Two patients had previously had AVR. The operation was carried out under cardiopulmonary by-pass. After obtaining 25 degrees C hypothermia the bypass was discontinued and the cerebral vessels were cannulated from inside of the opened aneurysm and perfused at a flow rate of 250 ml/min. The myocardium was protected by cold cardioplegia and topical cooling. During total circulatory arrest the distal aortic arch anastomoses were completed in 28-56 minutes. Then the by-pass was restarted and the rest of the operation was carried out as usual. One patient with an acute dissecting aortic aneurysm died on the 2 post-operative day due to brain damage and rupture of abdominal aorta. The other patients recovered well. There were no permanent neurological or myocardial complications. Three patients had a transient renal failure, one needing dialysis. The 8 survivors have done well 4-46 months after the operation.     

Aortic complications after bicuspid aortic valve replacement: long-term results

BACKGROUND: Bicuspid aortic valve (BAV) is a risk factor for aortic dissection and aneurysm. We studied patients with BAV and tricuspid aortic valve (TAV) to evaluate long-term changes in the ascending aorta after aortic valve replacement (AVR). PATIENTS AND METHODS: One hundred consecutive patients were allocated into two groups according to the presence of BAV (group A, 50 patients) or TAV (group B, 50 patients). Mean age was 51 +/- 12 years in group A, and 50 +/- years 12 in group B. No patients had hypertension or Marfan's syndrome. Until July 2001, mean follow-up was 234 +/- 47 months in group A and 241 +/- 43 months in group B. RESULTS: Five patients (10%, CL 5.7 to 13.9) in group A suffered late acute aortic dissection. Acute aortic dissection (5 vs 0, p = 0.0001) and sudden death (7 vs 0, p = 0.0001) occurred more frequently in patients with BAV. All survivors were assessed by echocardiogram. The mean diameter of the ascending aorta was 48.4 mm in group A and 36.8 mm in group B. Three patients in group A were operated on because of ascending aorta aneurysm more than 6 cm in diameter. CONCLUSIONS: As a result of our experience, we recommend a policy of prophylactic replacement of even a seemingly normal and definitely a mildly enlarged ascending aorta in cases of BAV at the moment of AVR, and consideration of a similar approach for any other cardiac surgical procedure in patients with BAV.     

Bilateral pneumothorax and rupture of dissecting aortic aneurysm following a mitral valve replacement in Marfan syndrome: a case report]

A 12-year-old girl with Marfan syndrome was referred to our department because of severe mitral regurgitation. The patient was pale and in a pre-shock condition. The echocardiogram revealed a chordae rupture of the posteromedial papillary muscle at the posterior leaflet. A moderate dilatation of the aortic annulus (30 mm) and the ascending aorta (45 mm) without aortic regurgitation was also observed. Emergent mitral valve replacement was performed without replacement of the aortic valve or the ascending aorta. After two months, the patient developed bilateral pneumothorax, which was resistant to continuous suction therapy and finally required surgical treatments. Despite the relatively uneventful recovery, a lethal rupture of dissecting aortic aneurysm into the pericardial cavity, developed four months after the initial operation. We discussed the desired surgical approaches and respiratory problems in patients with connective tissue disorder.     

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。     

Aortic intramural hematoma with severe aortic regurgitation.

A 71-year-old Japanese woman with severe chest pain was diagnosed with Stanford type A acute aortic dissection. After 3 months of medical treatment, she was operated on under a diagnosis of dissecting aneurysm of the ascending aorta and severe aortic regurgitation. Operative findings showed prolapse of the redundant aortic leaflets and a dilated ascending aorta without intimal tears. Operative and computed tomography findings differed from those of a classical dissection, which was the primary diagnosis of this patient, and were compatible with a diagnosis of aortic intramural hematoma (IMH). Few reports of IMH include concomitant aortic regurgitation. Surgery involved aortic root remodeling and prosthetic graft replacement of the ascending aorta.     

Aortic intramural hematoma with severe aortic regurgitation

A 71-year-old Japanese woman with severe chest pain was diagnosed with Stanford type A acute aortic dissection. After 3 months of medical treatment, she was operated on under a diagnosis of dissecting aneurysm of the ascending aorta and severe aortic regurgitation. Operative findings showed prolapse, of the redundant aortic leaflets and a dilated ascending aorta without intimal tears. Operative and computed tomography findings differed from those of a classical dissection which was the primary diagnosis of this patient, and were compatible with a diagnosis of aortic intramural hematoma (IMH). Few reports of IMH include concomitant aortic regurgitation. Surgery involved aortic root remodeling and prosthetic graft replacement of the 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.     

Staged surgical repair for extensive cardiovascular damage by syphilis

A 45-year-old man had aortic regurgitation with a syphilitic true aneurysm of the ascending to transverse arch aorta and a descending aortic aneurysm from chronic Stanford type B aortic dissection. After antibiotic therapy, two-staged surgical repair was performed and there has been no evidence of recurrence in 12 months since the second stage. We describe the successful management of extensive cardiovascular syphilitic damage.     

Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency and marked displacement of the coronary ostia.

Six patients with a large aneurysm of the ascending aorta involving the root of the aorta and severe aortic valve insufficiency owing to marked annular dilatation were treated by replacement of the ascending aorta and aortic valve with a composite unit. It was also necessary to transpose the origin of the coronary arteries with the use of saphenous vein grafts. In 3 patients, the aneurysm was due to a chronic dissection. In one patient, the aneurysm extended beyond the arch of the aorta. There were no operative deaths. One patient died suddenly of pulmonary emboli 11 months after surgery. The remaining 5 patients are doing well, 5 months to 4 years postoperatively.     

A false aneurysm with an aorto-superior vena cava fistula after replacement of the ascending aorta: report of a case

A 58-year-old female presenting with congestive heart failure due to a fistula between an aortic false aneurysm and the superior vena cava (SVC) is described. She had a history of Takayasu’s arteritis (TA) and she had undergone aortic valve and ascending aorta replacement and coronary artery bypass grafting 6 years before. The false aneurysm had occurred 1 year after the surgery, and she had been conservatively managed. The operation revealed that the cause of the false aneurysm was the detachment of the two proximal saphenous vein anastomoses to the ascending aortic graft. After the surgery, the patient made an uneventful recovery. A false aneurysm of the ascending aorta is one of the most serious complications after replacement of the ascending aorta for patients with TA (Miyata et al. in J Vasc Surg 27:438–445, 1998). We herein present the exceptional case of a fistula between an aortic false aneurysm and the SVC that occurred after ascending aorta graft replacement.     

Results of aortic valve-sparing operations.

OBJECTIVE: To review the late results of valve-sparing operations in patients with aortic root aneurysm and in those with ascending aortic aneurysm and aortic insufficiency. METHODS: From May 1988 to June 2000, 120 patients with aortic root aneurysm and 68 with ascending aortic aneurysm and aortic insufficiency underwent aortic valve-sparing operations. Patients with aortic root aneurysm were younger, were predominantly male, and had less severe aortic insufficiency than patients with ascending aortic aneurysm, who were older and often had aneurysm of the transverse arch. Forty-eight patients with aortic root aneurysm had the Marfan syndrome. The prevalence of aortic dissection was similar in both groups. Reconstruction of the aortic root was performed by reimplanation of the aortic valve in 64 patients and by remodeling of the aortic root in 56. Patients with ascending aortic aneurysm and aortic insufficiency were treated by replacement of the ascending aorta with reduction in the diameter of the sinotubular junction. Approximately two thirds of the latter patients also required replacement of the transverse aortic arch. The mean follow-up was 35 +/- 31 months for patients with aortic root aneurysm and 26 +/- 23 months for those with ascending aortic aneurysm. RESULTS: There were 2 operative and 5 late deaths in patients with aortic root aneurysm and 1 operative and 9 late deaths in patients with ascending aortic aneurysm. The 5-year survival for patients with aortic root aneurysm was 88% +/- 4% and for patients with ascending aortic aneurysm, 68% +/- 12% (P =.01). Severe aortic insufficiency developed in 2 patients, and they required aortic valve reoperation. The 5-year freedom from aortic valve reoperation was 99% +/- 1% for patients with aortic root aneurysm and 97% +/- 4% for those with ascending aortic aneurysm. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 5-year freedom from severe or moderate aortic insufficiency was 90% +/- 4% in patients who had aortic root aneurysm and 98% +/- 2% in those who had ascending aortic aneurysm. CONCLUSIONS: Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first 5 years of follow-up.     

A case of ascending aortic pseudoaneurysm in a patient with aortic replacement

A 59-year-old man with a history of ascending aorta replacement for an aortic dissection using gelatin–resorcin–formalin glue at age of 50 years presented with paroxysmal nocturnal dyspnea. An echocardiogram showed severe aortic regurgitation associated with aortic root enlargement. Chest computed tomography showed that the ascending aorta was dilated and a pseudoaneurysm was observed around the implanted prosthetic graft. Upon opening the ascending aorta, we found that the posterior wall of the proximal anastomotic portion of the implanted graft was ruptured. After replacement of the aortic root with a composite graft and reconstruction of the orifices of the right and left coronary arteries, total arch replacement by the separated graft technique was performed. The postoperative course was uneventful.     

Coronary malperfusion due to flap suffocation after acute type A dissection surgery

A 24-year-old man presented with chest pain. He was diagnosed as having a type A acute aortic dissection and an annulo-aortic aneurysm. After emergency surgery for an aortic root replacement, his electrocardiogram showed ST-segment depression and T-wave inversion. Echocardiography showed asynergy of the left ventricle without coronary ostial pathology. Heart catheterization revealed no coronary stenosis, but the true lumen of the residual ascending aorta had extreme diastolic narrowing due to flap suffocation. This resulted in coronary malperfusion. The pullback pressure curve confirmed the mechanism. The patient underwent a surgical re-intervention for a total arch repair, which diminished the coronary malperfusion. At a follow-up appointment four years and four months later, the patient was doing well.     

A case of ruptured aneurysm of the thoraco-abdominal aorta associated with Beh?et's disease

A 41-year-old male with incomplete type of Beh?et's disease was operated on because of ruptured aneurysm of the thoraco-abdominal aorta. A saccular pseudoaneurysm developed by rupture of the aortic wall involved the left postero-lateral portion of the supra-renal abdominal aorta. The defect in the aneurysm was closed using Dacron patch. The post-operative course was uneventful. However, seven months after discharge, the patient developed severe back pain at midnight, and was referred to our institution. On physical examination, a pulsatile mass was found in the right epigastric area. CT and DSA showed saccular pseudoaneurysm at the patch anastomotic site. Extra-anatomic long bypass grafting was performed from the ascending aorta to the infra-renal abdominal aorta. The abdominal aorta was occluded just below the diaphragm and the supra-renal portion of the aorta. Reconstruction of coeliac artery and superior mesenteric artery was made using branch grafts attached to the long graft. Surgical treatment of the complicated Beh?et's disease should include extra-anatomic bypass, especially in the re-operative cases of ruptured aneurysm of the aorta.     

Double aortic arch with aneurysm-a surgical case report.

An unusual case of double aortic arch with aneurysm is described. A 61-year-old, hypertensive and syphilitic male patient complained of increasing difficulty in swallowing of approximately five months duration. Barium swallow and subsequent aortography showed the presence of an aneurysm of the ascending aorta involving the left (anterior) arch of the double aortic arch. The tightening of the vascular ring by aneurysmal dilatation of the left aortic arch appeared to be responsible for the delayed onset of the symptom. Surgical correction was made by removing the aneurysmal ascending aorta and left aortic arch and a Dacron graft was inserted between the ascending aorta and the right (posterior) aortic arch. The patient died of cerebral complication about forty hours postoperatively. Surgical problems associated with this unusual condition were discussed retrospectively from the operative and autopsy findings. In reviewing the pertinent literatures this case appeared to be the first operated case of double aortic arch associated with aneurysm.     

Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta

PURPOSE: The current therapy for type A aortic dissection is ascending aortic replacement. Operative mortality and morbidity rates have been markedly improved because of recent advances in surgical techniques and anesthesiology. However, type A aortic dissection with an entry tear in the descending thoracic aorta is still a surgical challenge because of the need for extensive aortic replacement. METHODS: Ten patients with type A aortic dissection were treated with endovascular stent-grafts. The false lumen of the ascending aorta was patent in five patients, and it was thrombosed in the other five patients. The entry tears were located in the descending thoracic aorta in all cases. Seven patients had acute dissection, and three patients had subacute dissection. Four patients had pericardial effusion. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents. RESULTS: Entry closure was achieved in all patients. Complete thrombosis of the false lumen of the ascending aorta was observed after stent-grafting in all patients. A second stent-graft was required in two patients to obtain complete thrombosis of the false lumen of the descending thoracic aorta. No procedure-related complications were observed, with the exception of a minor stroke in one patient. During a mean follow-up period of 20 months, no aortic rupture or aneurysm formation was noted in either the ascending or descending thoracic aorta, and all patients were alive and doing well. The abdominal aortic aneurysm enlarged after stent-grafting in one patient, and this was treated by closing the fenestrations of the abdominal aorta with stent-grafts. CONCLUSION: Stent-graft repair of aortic dissection with an entry tear in the descending thoracic aorta is a safe and effective method and may be an alternative to surgical graft replacement in highly selected patients.     

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.     

Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients

BACKGROUND: This analysis was performed to evaluate the results of reoperations on the ascending aorta and aortic root. METHODS: All reoperations (n = 134) on the aortic root and ascending aorta performed between February 1981 and April 1998 were retrospectively analyzed. Indications for reintervention were a true or false aneurysm (35%), acute dissection (3.0%), aortic valve stenosis and/or insufficiency (23.1%), prosthetic valve endocarditis (32.8%), and combinations (4.5%). The principal reoperations performed were aortic root replacement (composite graft, freestyle, aortic allograft, or pulmonary autograft) in 116 patients, ascending aortic replacement in 10 patients, and closure of a false aneurysm in 5 patients. Results were analyzed using univariate statistical methods. RESULTS: Hospital mortality was 6.6% (8 patients). Univariate predictors of hospital death were preoperative functional class III or IV (p = 0.02), an interval of less than 6 months between the primary and actual operation (p = 0.02), preoperative creatinine level of more than 200 micromol/L (p = 0.001), acute aortic dissection (p = 0.001), intraoperative technical problems (p = 0.001), and postoperative dialysis (p = 0.001). Freedom from repetitive reoperation was 99% at 1 year and 98% at 5 and 10 years. CONCLUSIONS: Reoperations on the aortic root and ascending aorta can be performed with an early mortality which is very acceptable.     

Cylindrical patch repair for circumferential subvalvular abscess due to prosthetic valve endocarditis

A 51-year-old male underwent aortic valve replacement and vascular prosthesis implantation due to an aneurysm of the ascending aorta combined with aortic regurgitation caused by the bicuspid aortic valve. Semi-emergency surgery was performed due to severe paravalvular leakage with prosthetic valve endocarditis 16 months after the 1st operation. The circumferential annular abscess cavities were closed with a cylindrical patch, and a mechanical valve was installed on the upper edge of the sutured cylindrical patch. A vascular prosthesis was reimplanted to the ascending aorta. Use of the cylindrical patch provides a good exposure of operative field to close circumferential annular abscess cavity.     

Unusual false aneurysm of the ascending aorta associated with ruptured acute type A aortic dissection

Abstract   False aneurysm of the thoracic aorta unrelated to trauma, or to previous aortic or cardiac surgery, is extremely rare. We encountered a case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection. The false aneurysm, which was contained by thin connective tissue surrounding the aortic wall, was located beside the false lumen of the dissected ascending aorta, expanding toward the transverse sinus. We immediately decided to perform an emergency operation. We noted the large entry site at the anterior wall of the dissected ascending aorta after resection of the flap. We identified the false aneurysm arising from a small tear of the false lumen. Graft replacement of the ascending aorta using a tube graft was performed. The postoperative course was satisfactory. This pathology was believed to be not only a consequence of hemostasis, but also a process of re-rupture of the dissected aorta.