Rigid intraluminal prosthesis for replacement of thoracic and abdominal aorta

During the past seven years, 80 patients have undergone aortic substitution using a rigid intraluminal prosthesis. There were 9 early deaths. The procedures involved 32 dissecting aneurysms (18 ascending and 14 descending), 16 atherosclerotic aneurysms of the ascending aorta and 13 atherosclerotic aneurysms of the descending aorta, 3 thoracoabdominal aneurysms, 2 arch aneurysms, and 14 abdominal aortic aneurysms. There was one early dislodgment of the rings necessitating reoperation, but no other early complications related to the procedure. In the follow-up period (mean, 25 months) there were 6 late deaths. One occurred 6 months after operation in a patient with empyema. There were no late complications of thrombosis, erosion, pseudoaneurysm formation, or hemorrhage. The follow-up data are extremely encouraging. We now are using this device whenever possible in all substitutions of the aorta, although in approximately 40% of patients, it is necessary to remove one of the spools and suture either the proximal or distal end of the graft owing to the close proximity of the aneurysm to the coronary ostia or the origin of the subclavian artery. Important techniques of insertion and postoperative angiograms are presented.     

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%.     

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.     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的总结21例升主动脉瘤合并主动脉瓣关闭不全的外科治疗经验。方法19例行Bentall手术,2例行Cabrol手术;5例同时置换二尖瓣。术前心功能IV级15例,III级6例。动脉瘤直径6～11 cm,平均(8.5±2.6) cm;17例主动脉内膜有撕裂,其中5例升主动脉远端仍有夹层。主动脉瓣环直径2.7～5.4 cm,平均(3.2±1.8）cm。超声心动图检查均示主动脉瓣严重关闭不全。结果手术后无早、晚期死亡,术后超声心动图和造影检查示主动脉瓣关闭良好,移植的冠状动脉通畅、无扭曲,效果满意。结论动脉瘤直径大于6 cm时应及时随访和做预防性手术,一旦发现夹层动脉瘤应立即手术,Bentall手术治疗升主动脉瘤效果良好。     

Surgical treatment of giant aneurysms of ascending parts and arch of the aorta in condition of deep hypothermia and circulatory arrest with artificial assisted circulation

Sternotomy in giant (10 cm and more in diameter) aneurysms is highly dangerous due to possibility of injury of aneurysmatic wall with fatal bleeding. That is why sternotomy in condition of artificial circulation (AC) and cooling of patients to 29-30 degrees C are preferred. Two cases of successful surgical treatment of critical patients with giant aneurysms of ascending parts and arch of the aorta in condition of femoro-femoral AC, hypothermia (20 degrees C) and circulatory arrest are presented. One of the patients had a giant false posttraumatic aneurysm of an ascending part of the thoracic aorta with fistula between aneurysm and pulmonary artery. Suturing of defects of ascending aorta and pulmonary artery wall, aneurysmorrhaphia of pulmonary artery were performed. The other patient with acute disruption of a giant dissected aortal aneurysm and hemomediastinum underwent prosthesis of ascending part and arch of the aorta.     

Multiple aneurysms and aortic dissection: An unusual manifestation of Marfan's syndrome

Annuloaortic ectasia and dissection of the ascending aorta are common cardiovascular complications of Marfan's syndrome. True aneurysms of the subclavian arteries in these patients are rare. We present an unusual case of a 37-year-old woman who over the span of 10 years sequentially developed an aneurysm of the ascending aorta (annuloaortic ectasia), a right subclavian artery aneurysm, a left axillary-subclavian artery aneurysm, and a dissection of the aortic arch. Aside from the aortic dissection, the aneurysms produced no symptoms. All vascular complications were detected with computed tomography and managed successfully. This case emphasizes the need for close postoperative surveillance in patients with Marfan's syndrome who have had one cardiovascular complication of the disease.     

Surgical treatment of thoracic aneurysm: a 5-year experience

The surgical results of 77 patients with an aneurysm of the thoracic or thoracoabdominal aorta who were surgically treated during a 5-year period were retrospectively evaluated. Eighty-four operations were performed. The aneurysm was located on the ascending aorta in 20 patients, on the arch in nine, and on the arch and ascending aorta in eight. Sixteen aneurysms involved the descending thoracic aorta and 27 were thoracoabdominal. Associated surgery was performed in 12 patients. Deep hypothermia and circulatory arrest were employed in 30 patients. Partial cardiopulmonary bypass was used in 15 patients. Mortality was significantly higher if operation was performed under emergency conditions: the early mortality rate was 11.7%. Aggressive surgical management of untreated aneurysm is justified, as rupture of such lesions is the most common cause of death and associated mortality is high, with a 5-year survival rate of less than 20%.     

Degenerative and atherosclerotic aneurysms of the thoracic aorta. Determinants of early and late surgical outcome

To identify significant predictors of early and late mortality, multivariate discriminant analyses were applied to the clinical outcome of 175 consecutive patients with thoracic aortic aneurysms operated upon over a 20 year span. Only atherosclerotic and degenerative aneurysms were included; the patients were segregated into two groups according to location of the aneurysm. The ascending aortic aneurysm group consisted of 124 patients, 85% of whom required concomitant aortic valve replacement. There were 51 patients in the descending aortic aneurysm group. Mean follow-up was 4.9 years (maximum of 19 years), with a total of 860 patient-years of follow-up. Multivariate analyses revealed that surgical priority and advanced age were independent determinants of hospital mortality in the ascending group; for the descending group, surgical priority and the presence of congestive heart failure were the strongest predictors of hospital mortality. Late mortality in the ascending group correlated with advanced age. Hypertension and the presence of preoperative congestive heart failure were independent determinants of late mortality in the descending group. Several variables did not have any independent bearing on hospital or late mortality, including etiology and location of the aneurysm, previous myocardial infarction, chronic lung disease, and concomitant aortic valve replacement. High-risk subgroups of patients with thoracic aortic aneurysms can be identified by these variables. Aggressive medical plus surgical management and operation prior to aneurysm rupture is necessary to improve both early and long-term survival rates.     

Rigid intraluminal prosthesis for replacement of thoracic and abdominal aorta

From December 1976 to April 1983, 55 patients underwent operations in which intraluminal ring grafts were used for replacement of thoracic and abdominal aortic aneurysms. Twenty-eight patients had dissections, and 11 had ascending aneurysms. There were 10 descending aneurysms; three of these were traumatic. There were two arch aneurysms, three abdominal aneurysms, and one thoracoabdominal aneurysm. The follow-up period was 78 months with a mean follow-up period of 24 months. There were six postoperative deaths and six late deaths. No evidence of complications of thrombosis, migration, erosion, or pseudoaneurysm resulting from the ring within the 78-month follow-up period was seen, and we conclude that this is a safe, reliable, quick method for replacement of the aorta in certain well-defined situations.     

A case of atherosclerotic aneurysm of the right subclavian artery with the right axillary arterial stenosis and enlargement of the ascending aorta

A 54-year-old man presented with neck pain and hoarseness. Angiography showed a rare right subclavian artery aneurysm, enlargement of the ascending aortic aneurysm, and axillary artery stenosis. These aneurysms would normally be treated with end-to-end anastomosis, but due to the complexity of the lesion in this case, we performed more extensive surgery. This consisted of successful reconstruction of the subclavian artery and replacement of the ascending aorta and aortic arch.     

Repair of Mycotic Aneurysms of the Aorta Involving the Aortic Valve

This report summarizes our successful management of 6 patients who underwent repair of mycotic aneurysms of the ascending aorta within a four-year period. Repairs have been successful despite involvement of as much as two-thirds of the circumference of the aortic valve annulus, involvement of the origin of the right coronary artery, and development of heart block. Three patients required surgical intervention because of hemodynamic decompensation before they had completed antibiotic therapy for endocarditis.In 3 patients, the aneurysm was buttressed with the valve skirt so that aneurysm repair and valve replacement were accomplished in continuity. In 2 patients, the aneurysm was repaired separately and the valve seated on the repair. In 1 patient, a large defect between the left and right coronary arteries was repaired with a woven Dacron patch secured to the valve skirt. The valve was seated to the left ventricle and the graft to the aorta. There were no operative or postoperative deaths. Our data suggest that mycotic aneurysms of the aortic annulus can be successfully repaired despite extensive damage.     

Aneurysms in the ascending aorta adherent to the sternum after cardiac surgery.

Sternotomy in a patient with an aneurysm in the ascending aorta adherent to the sternum after cardiac surgery can result in fatal hemorrhage or brain damage unless the distal ascending aorta can be identified and secured immediately. A left anterolateral thoracotomy was used in three patients with adherent aneurysms. The distal ascending aorta was isolated, and dissection was performed between the aneurysm and the sternum. There was no complication. This method was safe, and blood loss was minimized.     

Idiopathic inflammatory aneurysm of the ascending aorta

Inflammatory aneurysms of the ascending aorta are exceedingly rare. The principal cause of ascending aortic aneurysms remains arteriosclerosis. We present a patient with an ascending aortic aneurysm caused by active inflammatory disease superimposed on complex atherosclerotic disease of the aorta.     

Marfan''s syndrome. Broad spectral surgical treatment cardiovascular manifestations

Most patients with Marfan's syndrome have cardiovascular manifestations and complications of these abnormalities lead to death in 50% of patients by the age of 32. This report is concerned with the performance of 79 operations to control these problems in 41 patients during a 16-year period. There were 3 early deaths and 11 late deaths, with survival at 15 years in 62%. The cardiovascular manifestations assumed eight patterns of involvement, in brief, consisting of aneurysms of ascending aorta, mitral valve insufficiency, aortic dissection and dissecting aortic aneurysm, and degenerative distal fusiform aortic aneurysm. These lesions occurred in isolated form or in association with others, hence the larger number of patterns of involvement. Various methods were employed in treatment of aneurysms of the ascending aorta, which was associated with aortic valvular insufficiency in most. The most reliable method of controlling disease at this level was composite valve graft replacement of fusiform aneurysms and separate valve graft operation for dissections occurring in the previously uninvolved aorta. Isolated mitral valve insufficiency was relieved by standard mitral valve replacement and this operation could be safely combined with composite valve graft replacement of the ascending aorta. More distant aneurysms of the aorta, either degenerative or chronic dissections, were susceptible to reconstruction as employed in the nonMarfan patient. Treatment of multiple lesions was staged, treating the more symptomatic condition first. Regular follow-up examination is important in these patients to detect new lesions and to evaluate known lesions. An aggressive approach is suggested in their treatment because 63% of the 11 late deaths in this series were due to lesions that could be successfully treated by presently available methods.     

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.     

Treatment of giant aortic aneurysm with tracheal compression and sternal erosion without circulatory arrest

Treatment of huge aneurysms involving the ascending aorta and the aortic arch with compression of the surrounding structures represents a surgical challenge. The case of a patient affected by respiratory insufficiency and sternal erosion caused by chronic giant aortic aneurysm is reported. The use of a stepwise approach and selective cerebral arterial perfusion ensured successful operative management, avoiding circulatory arrest and enabling an expeditious postoperative recovery.     

Composite graft replacement after aortic valvuloplasty in Takayasu arteritis

A 24-year-old woman had undergone valvuloplasty of the aortic valve and external reinforcement of an aneurysm of the ascending aorta during the active phase of Takayasu arteritis 1 year prior to admission to our hospital. On examination, she was diagnosed as having a large false aneurysm of the ascending aorta with annuloaortic ectasia and severe aortic regurgitation, bilateral common carotid artery aneurysms with a left internal carotid artery saccular aneurysm, and bilateral subclavian artery and right vertebral artery obstructions due to Takayasu arteritis. Because of the risk of rupture, surgical intervention was carried out in spite of the fact that aortitis was in the active phase.     

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.     

Repair of an ascending aortic aneurysm using reduction aortoplasty in a Jehovah's Witness

Reduction ascending aortoplasty has been advocated as a possible alternative to traditional graft replacement for treatment of aneurysms of the ascending aorta and root. We report a case of a 58-year-old Jehovah's Witness female, with a 5.5-cm ascending aortic aneurysm and critical aortic stenosis. She underwent aortic valve replacement and reduction aortoplasty buttressed with a Dacron graft. We reviewed the history and contemporary applications of this technique and concluded that aortic reduction with externally supported aortoplasty may represent a viable option to treat Jehovah's Witness patients with ascending aorta and root aneurysm.     

Saccular Aortic Aneurysms

Most vascular surgeons believe that saccular aortic aneurysms have a more ominous natural history than the typical fusiform aneurysm, although this is not documented in the literature. Expeditious repair is indicated for symptomatic saccular aneurysms, and intervention is usually advocated even when they are asymptomatic because of the general belief that their unique shape predisposes them to rupture. The objective of this report is to review the presentation and surgical management of this uncommon pathology. The records of 10 patients who underwent surgical intervention for an aortic saccular aneurysm between 1985 and 1998 were reviewed. To summarize their presentation and management, we grouped patients according to anatomic location: group A (distal arch), group B (descending thoracic aorta), group C (visceral aorta), and group D (infrarenal aorta). From analysis of these data we conclude that although saccular aortic aneurysms are rare, when present, they are most commonly found in the thoracic and suprarenal aorta. Most cases treated with surgery are symptomatic. Most thoracic and suprarenal saccular aneurysms can be repaired with a patch graft, which spares thoracic intercostals. Repair of saccular aneurysms of the distal arch are only feasible when performed with the use of hypothermic circulatory arrest. Infrarenal saccular aneurysms generally require tube graft replacement because the coexistent atherosclerosis makes patch repair difficult. Endovascular techniques may be the procedure of choice in the future.