Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Thoracic aortic aneurysm associated with congenital bicuspid aortic valve.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1981 and August 1997, 25 patients with an aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at the authors' institution. There were 20 males and five females. The age of the patients ranged from 27 to 74 years (mean 53 years). There were 18 patients with true ascending aortic aneurysms (of which 10 presented with annulo-aortic ectasia) and seven with dissecting aortic aneurysms (four with DeBakey type I dissection, two with type II and one with type IIIb). These 25 patients constituted 2.6% (25/973) of all cases of surgical operations for aneurysms in the thoracic aorta. Aortic valve dysfunction was noted in 20 patients. The authors performed a valved conduit operation in nine patients, aortic valve replacement and wrapping of the ascending aorta in six, graft replacement of the ascending aorta in five, graft replacement of the ascending aorta and aortic arch in four, and graft replacement of the descending aorta in one. No hospital deaths occurred in the authors' patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 11 patients and mucoid degeneration in nine. In patients with congenital bicuspid aortic valve, attention should be paid to aneurysmal dilatation and aortic dissection as complications in addition to valve dysfunction.     

Surgical repair of dissection of the upper descending thoracic aorta and discrete ascending aortic aneurysm.

This report describes successful staged surgical repair in 2 patients with dissection of the upper descending thoracic aorta (DeBakey type III) with coexisting discrete Marfan's aneurysms of the ascending aorta. Initial repair of the descending aortic dissection was done through a left thoracotomy using a transverse aorta--femoral artery shunt in 1 patient and a left ventricular apex--femoral artery shunt without systemic heparinization in the other. Emphasis is placed on the need for pharmacological reduction of blood pressure during aortic cross-clamping as well as the use of a shunt to prevent dissection of the ascending aortic aneurysm. In both patients, subsequent repair of the ascending aortic aneurysm was accomplished using composite graft replacement of the aortic valve and ascending aorta. This operation is advised for such patients even in the absence of notable aortic valve incompetence.     

Surgery for aortic dissection associated with congenital bicuspid aortic valve

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to the development of dissecting aortic aneurysms. Between 1981 and October 1997, 7 patients with aortic dissection associated with congenital bicuspid aortic valve underwent surgical treatment at our institution. The patients consisted of six males and one female. The age of the patients ranged from 54 to 74 years (mean 61 years). The classification of dissecting aortic aneurysms was DeBakey type I dissection in 4 patients, type II dissection in 2 patients and type IIIb dissection in 1 patient. These 7 patients constituted 2.0% (7/356) of all cases of surgical operation for dissecting thoracic aneurysm. Aortic valve dysfunction was noted in 5 patients, 4 of whom had previously undergone aortic valve replacement. We performed graft replacement of the ascending aorta in 4 patients, graft replacement of the ascending aorta and aortic arch in 2 patients, and graft replacement of the descending aorta in 1 patient. There were no hospital deaths in any of the 7 patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 2 patients and mucoid degeneration in 4 patients. In addition to complication by valve dysfunction, patients with congenital bicuspid aortic valve are at risk for the development of aortic dissection.     

Survival in Thoracic or Thoracoabdominal Aortic Aneurysm: Comparison between patients with or without surgical treatment

The surgical mortality among 22 patients treated for thoracic or thoracoabdominal aneurysm was compared with the mortality in 47 patients managed without surgery. Surgical mortality (<30 days) was low (1/13) in ascending aortic aneurysm, but higher (3/8) in aneurysm of the descending or thoracoabdominal aorta (including both acute and elective operations). Of the 20 non-surgically managed patients in the latter group, 15 died after a mean of 1.1 year. The only patient operated on for aortic arch aneurysm died of cerebral ischaemia 2 days postoperatively. Most of the 19 non-operated patients with aneurysm of the arch or total aorta (mean age 76 years) were never considered for surgical treatment. The analysis supports aggressive management of patients with aneurysm of the ascending, descending or thoracoabdominal aorta. Many of our patients with aneurysm of the arch or involving most of the aorta were old and had other, concomitant diseases, and in such cases an aggressive treatment strategy does not seem justified.     

Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta

BACKGROUND: Aneurysms of the ascending, arch, and descending thoracic aorta are typically managed with two operations. The first stage involves replacement of the ascending and arch aorta leaving a segment of graft in the proximal descending aorta with a mortality and stroke risk of 8%. The second stage involves replacement of the descending aorta with a mortality of 5% and a paraplegia risk of 5% to 10%. Some patients refuse surgical completion and others are at increased risk to undergo the second stage thoracotomy, leaving them with untreated descending thoracic aortic aneurysms vulnerable to rupture. A single-stage transmediastinal operation used in 14 patients is described. METHODS: Under circulatory arrest, the descending thoracic aorta is opened. A wire is passed up to the arch and a graft is brought down and secured excluding the descending thoracic aneurysm. The arch vessels are attached as a single patch and the graft is brought forward, replacing the ascending aorta. RESULTS: Fourteen patients have undergone single-stage replacement of the ascending, arch, and descending aorta with a 14% mortality rate and 14% incidence of paraplegia. CONCLUSIONS: Patients with aneurysms of the ascending, arch, and descending thoracic aorta can be managed with a single operation with comparable mortality and morbidity of the two-stage approach.     

Natural history of thoracic aortic aneurysms: indications for surgery,and surgical versus nonsurgical risks

BACKGROUND: The natural history of thoracic aortic aneurysm is incompletely understood. Over the last 10 years, at Yale University we have maintained a large computerized database of patients with thoracic aortic aneurysms and dissections. Analysis of this database has permitted insight into fundamental issues of natural behavior of the aorta and development of criteria for surgical intervention. METHODS: Specialized statistical methods were applied to the prospectively accumulated database of 1600 patients with thoracic aneurysm and dissection, which includes 3000 serial imaging studies and 3000 patient years of follow-up. RESULTS: Growth rate: the aneurysmal thoracic aorta grows at an average rate of 0.10 cm per year (0.07 for ascending and 0.19 for descending). Critical sizes: hinge points for natural complications of aortic aneurysm (rupture or dissection) were found at 6.0 cm for the ascending aorta and 7.0 cm for the descending. By the time a patient achieved these critical dimensions the likelihood of rupture or dissection was 31% for the ascending and 43% for the descending aorta. Yearly event rates: a patient with an aorta that has reached 6 cm maximal diameter faces the following yearly rates of devastating adverse events: rupture (3.6%), dissection (3.7%), death (10.8%), rupture, dissection, or death (14.1%). Surgical risks: risk of death from aortic surgery for thoracic aortic aneurysm was 2.5% for the ascending and arch and 8% for the descending and thoracoabdominal aorta. Genetic analysis: family pedigrees confirm that 21% of probands with thoracic aortic aneurysm have first-order family members with arterial aneurysm. CONCLUSIONS: In risk/benefit analysis the accumulated data strongly support a policy of preemptive surgical extirpation of the asymptomatic aneurysmal thoracic aorta to prevent rupture and dissection. We recommend intervention for the ascending aorta at 5.5 cm and for the descending aorta at 6.5 cm. For Marfan's disease or familial thoracic aortic aneurysm, we recommend earlier intervention at 5.0 cm for the ascending and 6.0 cm for the descending aorta. Symptomatic aneurysms must be resected regardless of size. Family members should be evaluated.     

Combined surgical and endovascular treatment of extensive thoracic aortic aneurysm

AIM: Patients with extensive aneurysm involving ascending aorta, aortic arch and descending aorta are usually treated by sequential operations. For these patients we can also use combined surgical and endovascular treatment. The experience with this procedure published in the literature is very limited. We report our experience in the 'elephant trunk' technique followed by an endovascular stent-grafting of the descending thoracic aorta in a small group of three consecutive patients with extensive thoracic aortic aneurysm. METHODS: Three consecutive patients with extensive thoracic aortic aneurysm or chronic dissection underwent combined surgical and endovascular treatment between January and December 2004. The procedure was carried out as a two-stage procedure. During the first stage aortic arch was replaced using the elephant-trunk' method and during the second stage the stentgrafting of the descending aorta was performed. RESULTS: All three patients were treated successfully. There was no death, no endoleak and no permanent neurological deficit. One patient had a transient paraparesis. In all patients the spiral CT demonstrated excellent technical result without endoleak and with thrombosis of the paraprosthetic space. CONCLUSIONS: We can conclude, that the combined surgical and endovascular treatment of extensive thoracic aortic aneurysm is a feasible method which could reduce mortality and morbidity. In our institution the elephant trunk technique followed by an endovascular stent-grafting of the descending aorta is the preferred method of treatment in patients with extensive thoracic aortic aneurysm involving ascending aorta, aortic arch and descending aorta.     

Debatable questions in the surgical treatment of thoracic aortic aneurysms

Some controversies in the surgical approach to thoracic aortic aneurysms are discussed. The author recommends: to perform echocardiography in patients with aortic aneurysms for detection of intracardiac pathology which may complicate the postoperative course; to combine thoracic aortography with selective coronary angiography in patients with thoracic aortic aneurysm for diagnosis of coronary artery disease; to operate asymptomatic fusiform aneurysm that measure twice or more the size of the normal aorta; to resect and replace dissections of the ascending aorta during cardio-pulmonary bypass; and to use active shunts during resection of the descending and thoraco-abdominal aneurysm.     

Aneurysm of the ascending aorta in its coarctation

In long-term period after resection of aorta coarctation, 9-14% patients developed aortic aneurysms, one third of them localized in the ascending aorta. From 146 patients operated on for aneurysm of the ascending aorta, 3 had aortic coarctation. In 2 patients aneurysms of the ascending aorta formed late after resection of the coarctation, the third patient was hospitalized with clinical picture of cardiac insufficiency at terminal stage due to coarctation of the aorta and a giant aneurysm of the ascending aorta with significant aortic insufficiency. The patients underwent successful surgeries: 1) ascending aorta grafting; 2) aortic valve and ascending aorta grafting by Bentallo de Bono method; 3) aortic valve and ascending aorta grafting by Bentallo de Bono method with bypass of descending aorta from the conduit. Cystic medianecrosis and two-volume aortic valve were revealed in all the patients. It is concluded that patients after surgery for coarctation of the aorta require long-term follow-up to defect cardiovascular complications early.     

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.     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Surgical technologies in the treatment of aneurysms of thoracic and thoraco-abdominal aorta

From 1993 to 2001 279 patients with aneurysms of the thoracic and thoracoabdominal aorta were operated. Cause of aneurysm formation in 74% cases was degenerative changes of aortal wall (Marfan's disease or Erdheim syndrome). Aneurysms were revealed in ascending aorta in 38 (14%) cases, in the ascending aorta with insufficiency of aortic valve--in 67 (24%), in the ascending aorta and aortic arch--31 (11%), in descending aorta--54 (19%), thoracoabdominal aneurysms--in 89 (32%). Twenty patients underwent surgery for combined aneurysms of the ascending aorta with it arch and descending part, thoracoabdominal aneurysms, and also for thoracic aneurysms in combination with coronary heart disease. Lethality in early postoperative period in patients with aneurysms of the ascending aorta was 5%, with aneurysms of the ascending aorta and insufficiency of the aortic valve--6.2%, in aneurysms of the ascending aorta and aortic arch--16.2%, in aneurysms of the descending aorta--6.4%, in thoracoabdominal aneurysms--15%.     

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.     

Thoracoabdominal aortic aneurysm repair through redo left-sided thoracotomy

BACKGROUND: The outcome of thoracoabdominal aortic aneurysm repair through redo-left thoracotomy after operations for descending thoracic aortic aneurysms was investigated. METHODS: Between May 1982 and March 2003, 100 patients underwent thoracoabdominal aortic aneurysm repair in elective surgery without profound hypothermic circulatory arrest. Thirty of these patients had previously undergone operations for descending thoracic aortic aneurysms. To evaluate the influence of previous descending thoracic aortic aneurysm repairs on the results of thoracoabdominal aortic aneurysm replacements, patients were divided into two groups: (1) patients who had previously undergone descending thoracic aortic aneurysm repair (group I; n = 30), and (2) patients who had not previously undergone descending thoracic aortic aneurysm repair (group II; n = 70). RESULTS: The distal aortic perfusion time and operation time were both longer in group I than in group II, but there was no significant difference between the two groups in total selective visceral and renal perfusion time or aortic clamp time. In-hospital mortality rates were 13% in group I and 19% in group II (p = 0.52). Major postoperative complications included paraplegia (10% of patients in group I and 4.3% of patients in group II; p = 0.36), renal failure requiring hemodialysis (20% of patients in group I and 11% of patients in group II; p = 0.35), respiratory failure (30% of patients in group I and 19% of patients in group II; p = 0.22). CONCLUSIONS: Previously descending thoracic aortic aneurysm and redo-left thoracotomy do not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy

Abstract   Background and Aim: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. Methods: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistant hypertension, were noted. Results: Six male patients with a mean age of 20.8 ± 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm—one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 ± 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. Conclusions: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.     

主动脉夹层的细化分型及其应用

目的探讨在Stanford分型的基础上根据主动脉夹层的部位和病变程度再进行细化分型,对指导临床选择手术时机、确定治疗方案和手术方式,以及判断预后的价值。方法1994年1月至2004年12月我院治疗主动脉夹层708例。其中Stanford A型夹层477例：（1）根据主动脉根部病变程度分为3型。A1型（主动脉窦部正常型）212例,行保留主动脉窦部的主动脉替换;A2型（主动脉窦部轻度受累型）72例,行主动脉窦部成形63例、David手术9例;A3型（主动脉窦部重度受累型）193例,行主动脉根部替换术（Bentall手术）。（2）根据主动脉弓部病变分为2型。C型（复杂型）78例,行主动脉弓部替换＋象鼻术;S型（单纯型）399例,行部分主动脉弓部替换。Stanford B型夹层231例,（1）根据主动脉扩张的范围分为3型：B1型：降主动脉无扩张或仅有近端扩张,147例,行腔内带膜支架主动脉腔内修复术103例（B1S型）、部分胸降主动脉替换术32例、部分胸降主动脉替换术＋远端支架象鼻术12例;B2型：全部胸降主动脉扩张,53例,行部分胸降主动脉替换术＋主动脉成形32例、全部胸降主动脉替换术21例;B3型：全部胸降主动脉及腹主动脉扩张,31例行胸腹主动脉替换术。（2）根据左锁骨下动脉和远端主动脉弓部是否受夹层累及分为2型：C型（复杂型）：夹层累及左锁骨下动脉或远端的主动脉弓部,44例,在深低温停循环下手术治疗;S型（单纯型）：远端主动脉弓部和左锁骨下动脉未受夹层累及,187例,介入治疗103例、手术治疗84例（常温阻断下手术60例,股动脉-股静脉转流下手术24例）。结果Stanford A型夹层住院病死率为4．6％（22／477）,并发症发生率为14．5％（69／477）。Stanford B型夹层：介入治疗组病死率1．9％（2／103）,并发症发生率为2．9％（3／103）,轻度内漏发生率为9．7％（10／103）;手术治疗组住院病死率为3．1％（4／128）,并发症发生率为18．8％（24／128）。结论细化主动脉夹层的分型对于术前判断手术时机、制定手术方案和初步判断预后,具有重要的指导作用。     

Self-expanding endovascular stent-graft implant for treatment of descending aortic diseases

A bstract Background: Aneurysms and dissections involving the descending thoracic aorta and the distal portion of the aortic arch are difficult to resolve surgically. The introduction of endovascular self-expanding stent-grafts has simplified the operation. Given the complications associated with their peripheral placement, we explored the feasibility of surgical insertion. Methods: Thirteen patients underwent surgical insertion of a stent-graft into the aortic arch via longitudinal aortotomy. Six patients had aneurysms (ruptured in two, and seven dissections (acute in two, ruptured in one). Five patients also underwent associated procedures including aortic valve replacement (one), ascending aorta replacement (two), arch replacement (one), and coronary artery bypass (one). Results: There was one intraoperative death due to ascending aortic dissection, and two hospital deaths due to multiple complications. Of ten patients discharged, one died 3 months postoperatively. The remaining survivors are well, and imaging studies confirmed adequate correction of the aortic disease. Conclusions: The use of this technique simplifies the operation and treatment of particular cases of aortic disease. The observed morbidity and mortality are due to factors independent of the technique.     

Composite graft repair of Marfan aneurysm of the ascending aorta: results in 100 patients

One hundred consecutive patients with the Marfan syndrome underwent composite graft repair of an ascending aortic aneurysm between September 1976 and June 1989. Twenty-two patients had ascending aortic dissection at the time of composite graft repair; 18 patients also had a mitral valve procedure. There were no hospital deaths among 92 patients undergoing elective repair. One of 8 patients undergoing emergency repair of a ruptured aneurysm died in the operating room. The overall hospital mortality rate was 1%. There have been ten late deaths among the 99 hospital survivors (10.1%). Five deaths occurred among the first 11 patients in this series and five occurred among the last 88 patients (5.7%). Three late deaths resulted from composite graft endocarditis; 3 other patients with endocarditis are alive after aortic root replacement with cryopreserved homografts. Late coronary dehiscence caused death in 1 patient and was successfully repaired in a second. Actuarial survival for the 100 patients was 92.6% at 5 years and 75.8% at 10 years. Currently, composite graft repair of Marfan aneurysms of the ascending aorta can be performed with low hospital and late mortality. Marfan aneurysms with a diameter of 6 cm or greater should be repaired with the Bentall composite graft procedure, even if the patient is asymptomatic.