Ruptured aortic dissecting aneurysm in Turner's syndrome: a case report and review of literature.

Cardiovascular malformations are frequently observed in Turner's syndrome. Bicuspid aortic valve and coarctation of the aorta are commonly associated with Turner's syndrome whereas aortic dissection is rare but its rupture results in death. We experienced a case of ruptured dissecting aneurysm (Stanford type A) in a 30-year-old female with Turner's syndrome. Emergent total arch replacement was performed successfully. A literature review revealed 32 cases of aortic dissection in patients with Turner's syndrome, including 15 cases of rupture. However, survival after rupture was reported only two cases. To our knowledge, this report descries the third known case of successful surgical management of ruptured aortic dissection in Turner's syndrome.     

Hybrid aortic arch repair for a ruptured and infected penetrating atherosclerotic ulcer of the aortic arch

Aortic arch rupture is a life-threatening emergency. Conventional open surgical repair carries a high mortality and morbidity. We report a case of an elderly patient who suffered from a ruptured and infected penetrating ulcer of the aortic arch. A hybrid operation was performed, consisting of a right-to-left carotid bypass and transposition of the left subclavian artery into the left common carotid artery followed by endovascular repair of the aortic arch. Antibiotic therapy, based on the results of culture and sensitivity tests for Staphylococcus aureus, was administered for 6 months. The patient recovered uneventfully and remains asymptomatic 16 months after the procedure. However, long-term follow-up is mandatory to determine the efficacy and the durability of this technique.     

Rupture of a dissecting thoracic aortic aneurysm into the pulmonary artery: successful surgical repair

A rare complication of dissecting thoracic aortic aneurysms is rupture into a cardiac chamber or great vessel with fistula formation. A case of congestive heart failure caused by a chronic DeBakey type I dissecting aortic aneurysm that ruptured into the pulmonary artery is reported. Surgical repair involved closure of the fistula followed by graft replacement of the ascending aorta and transverse aortic arch. A review of the literature revealed no previous reports describing successful repair of this lesion. A clinical picture consistent with concomitant aortic dissection and biventricular heart failure, especially when a continuous cardiac murmur is present, suggests the diagnosis of an aortopulmonary arterial fistula caused by a ruptured dissecting thoracic aortic aneurysm. Various imaging studies confirm the diagnosis.     

Uncovered stent-graft in the treatment for residual patent false lumen after surgical repair for acute type A aortic dissection

Patent false lumen after surgery for acute type A aortic dissection (AAAD) influences the outcome with increased risk of aortic rupture and visceral malperfusion. We report a case of a patient previously operated on for aortic valve repair and replacement of the ascending aorta because of AAAD, presenting at follow-up with a retrograde dissection in aortic arch, persistent patent false lumen and significative aortic enlargement. An extensive (arch and thoraco-abdominal aorta) successful repair was performed using uncovered stent grafts. We welcome discussion on the real indication of this alternative approach and advantages and disadvantages on mid-/long-term follow-up.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade; report of a case

The ruptured aortic arch aneurysm with cardiac tamponade is rare and has severely high mortality. We report a case of ruptured aortic arch aneurysm with cardiac tamponade. A 66-year-old man who had syncope attack was transferred to city hospital. Brain computed tomography (CT) showed no significant lesion and he admitted to our hospital for suspecting of aortic dissection. Chest CT showed ruptured aortic arch aneurysm and pericardial effusion. Emergent operation was done on the same day. It was found that the hematoma beneath the tunica adventitia existed at the distal arch and extended to the ascending aorta. Cardiac tamponade was caused by rupture of subadventitial hematoma in pericardial space. Aortic arch replacement was performed using selective cerebral perfusion under deep hypothermia. Postoperatively, he had no cerebral complication and was discharged uneventfully.     

Cardiac tamponade secondary to rupture of a distal aortic arch aneurysm

We report the rare rupture of a distal aortic arch aneurysm protruding into the pericardial cavity. A 70-year-old woman who suddenly lost consciousness and was transferred to our hospital by ambulance in profound shock was found in emergency computed tomography and echocardiography to have a dilated distal aortic arch and massive pericardial effusion. Suspecting that a distal aortic arch aneurysm had ruptured, causing cardiac tamponade, we undertook an operation. We found a defect in the aneurysmal wall leading to the pericardium near the main pulmonary artery that was plugged temporarily with an atheromatous mass. We conducted total arch replacement successfully under selective cerebral perfusion and moderate hypothermia.     

A new paradigm in the management of acute type A aortic dissection: Total aortic repair

The currently accepted guidelines of open surgical repair for acute type A aortic dissection include the resection of the primary entry tear, replacement of the ascending aorta and “hemi-arch” with an open distal anastomosis, and aortic valve resuspension and some form of obliteration of the aortic root false lumen. The principal aim is protection against aortic rupture, aortic regurgitation, and coronary ischemia and restoration of antegrade preferential true lumen perfusion. Proponents argue that this operation is tailored to be in the armamentarium of most cardiac surgeons and deliver the lowest early operative risk while leaving the infrequent long-term sequelae to be dealt with electively by experienced aortic centers. Although this may sound to be a compelling argument, the actual outcomes suggest that it falls significantly short of achieving its noble goals on both acute and chronic counts. This led us to develop a seemingly more radical paradigm, which aims to achieve total aortic healing in the acute phase. We describe a total aortic repair technique for acute type A aortic dissection consisting of “branch first” total arch repair, followed by thoracoabdominal stenting and balloon rupture of the septum. The total aortic repair technique ensures that the aortic valve, ascending aorta, and arch are surgically securely repaired, and provides complete decompression of the false lumen as well as internal support in the remainder of the aorta. This has provided excellent early results and will hopefully minimize future complications and interventions.     

Rupture of a small fusiform thoracic aortic aneurysm

We report a case of ruptured aortic aneurysm of the distal aortic arch. This aneurysm was fusiform and only 4.0 cm in maximum diameter: Emergency total aortic arch replacement was successful. Rupture of a thoracic aortic aneurysm of this shape and size is possible but extremely rare.     

Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion

Conventional surgical treatment of a ruptured aortic arch aneurysm is a challenging approach with a high rate of adverse outcomes. The midsternotomy can be complicated by total aortic disruption with often fatal massive hemorrhage. A preliminary cardiopulmonary bypass with peripheral cannulation and cooling is often preferred. Endovascular stents have been used in patients with thoraco-abdominal aneurysms, with good results. Its lone utilization for rupture of aortic arch aneurysm is not feasible because of the unavoidable occlusion of cerebral vessels' origins. A previous aorto-bicarotid bypass is mandatory and it requires the midsternotomy. Hence, we developed a combined technique. We performed a hybrid approach in a 74-year-old patient, affected by an aortic arch aneurysm, ruptured in its antero-inferior portion. First we ensured brain perfusion with a temporary surgical extra-anatomic (femoral-bicarotid) bypass. Then an endovascular stent graft was expanded from the distal portion of ascending aorta to the proximal one of the thoracic aorta, thus excluding the ruptured portion of the aortic arch. Then the patient underwent the definitive aorto-carotid bypass. This specific combined technique allows the complete treatment of a ruptured arch aneurysm, lowering the risks connected with sternothomic approach, mainly with previous cardiopulmonary bypass and deep hypothermic circulatory arrest.     

Double-barreled cannon stent grafts: possible solution for extremely dilated landing zone of aorta

Anatomical limitations have been identified as barriers to the more widespread application of thoracic endovascular aortic repair. Here, we report a case in which a novel technique was used as a solution for an extremely dilated aortic landing zone. An elderly gentleman in profound shock was diagnosed with a ruptured distal aortic arch aneurysm. Open repair was considered, but owing to the presence of multiple comorbidities and an extremely dilated aorta in the landing zone (45 mm) which made thoracic endovascular aortic repair infeasible, it appeared to entail a high risk for perioperative morbidity and mortality. Therefore, to save the patient's life, we designed a novel double-barreled cannon thoracic endovascular aortic repair method, and further developed a formula for choosing appropriate stent graft sizes. The patient gradually recovered to baseline physical status after the operation.     

Median sternotomy and extended left anterior thoracotomy for repair of traumatic aortic transection with ruptured right atrium

A 22-year-old man presented with traumatic aortic transtion associated with rupture of the right atrium and underwent urgent median sternotomy to repair the right atrium. A T-shaped extended left anterior thoracotomy was performed, and ruptured descending thoracic aorta was repaired under total bypass. A Y-shaped connector was inserted in the arterial catheter to allow cannulation of both ascending aorta and femoral arteries. A 4-cm long Hemoshield graft was used to repair the aortic transection. The patient made a full recovery and was discharged 13 days after the accident.     

Staged hybrid repair using telescoped stent graft fixation for aortic arch and descending aortic aneurysms

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.     

Chronic rupture of abdominal aortic aneurysm

Although the mortality rate after abdominal aortic aneurysm rupture approximates 90% despite the urgent management, a few cases of chronic rupture and delayed repair have been reported in the world literature; anatomic and hemodynamic reasons occasionally allow for the fortunate course of these patients. We report in this article the case of 76-year-old man with a ruptured abdominal aortic aneurysm who was transferred to our facility 4 weeks after his initial hospitalization in a district institution and who finally had a successful open repair.     

Combined traumatic avulsion of the aortic valve and rupture of the left common carotid artery.

A case of complete rupture of the left common carotid artery at the aortic arch and avulsion of a cusp of the aortic valve due to blunt trauma is presented. The ruptured carotid artery was reimplanted into the left subclavian artery, and the avulsed aortic valve cusp was successfully repaired by direct suturing.     

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.     

Transesophageal echocardiography. Preliminary results in patients with traumatic aortic rupture

Eleven patients with blunt chest trauma at risk for traumatic aortic rupture underwent transesophageal echocardiography to image the descending aorta. Diagnoses were compared with the results of radiographic studies. Ten of the 11 patients underwent arch aortography, with positive results in six cases. In one patient, the results of a computed tomographic scan were interpreted as consistent with aortic rupture. The results of transesophageal echocardiography were positive for ruptured descending aorta in three of six patients with positive aortographic findings, and negative in eight patients. All three patients with positive findings had the diagnosis of ruptured descending aorta confirmed at surgery. The remaining eight patients demonstrated no aortic morbidity. These preliminary findings suggest that transesophageal echocardiography is a useful technique for the diagnosis of ruptured descending aorta following blunt chest trauma.     

Multivariate analysis of predictors of late stroke after total aortic arch repair.

OBJECTIVE: The number of aortic surgeries has recently increased, with improvement of outcome due to the development of various novel operative techniques and adjuncts. Although the postoperative incidence of stroke, the most severe complication of aortic surgery, is still a matter of concern and has been described well previously, late stroke after aortic arch repair has not been described well. We assessed the incidence and predictors of late stroke after total aortic arch repair. METHODS: From January 1993 to December 2003, 470 patients underwent total aortic arch repair in our institution. All patients, whether undergoing elective, urgent, or emergent aortic arch repair, were included. Emergent operation was required for 115 patients because of rupture or acute type A dissection. For brain protection, retrograde cerebral perfusion was used in 27% (125) and selective cerebral perfusion in 75% (353) of cases. The follow-up period was 32.5+/-31.5 months. Late stroke was defined as stroke occurring more than 30 days postoperatively. RESULTS: The incidence of early postoperative stroke was 4.9% (23/470), while that of late postoperative stroke was 6.0% (28/470). On univariate analysis, postoperative atrial fibrillation (P=0.014), preoperative prevalence of craniocervical lesions (P=0.0001), and advanced age (P=0.046) were each significantly related to late stroke. A Cox proportional hazards model detected postoperative atrial fibrillation (P=0.013, OR=3.02, 95% CI: 1.26-7.24) and preoperative prevalence of craniocervical lesions (P=0.0001, OR=5.37, 95% CI: 2.30-12.52) as predictors of late stroke. CONCLUSIONS: Postoperative atrial fibrillation and preoperative prevalence of craniocervical lesions were found to be risk factors for late stroke after total aortic arch repair.     

Endovascular management of a ruptured thoracoabdominal aneurysm-damage control with superior mesenteric artery snorkel and thoracic stent-graft exclusion

We report a case of a large ruptured thoracoabdominal aortic aneurysm, which was stabilized with endovascular aortic exclusion and snorkel bypass of the superior mesenteric artery (SMA). An 80-year-old African American woman with multiple medical comorbidities and previous open infrarenal abdominal aortic aneurysm repair presented with a ruptured 10.7 × 7.3 cm thoracoabdominal aortic aneurysm involving the origins of the renal and mesenteric vessels. The patient underwent emergent endovascular aortic repair with placement of a covered stent into the SMA coursing parallel to the aortic endograft. This technique was initially successful in clinically stabilizing the patient; however; 3 weeks after the initial procedure, she presented with recurrent rupture necessitating proximal extension of her snorkeled SMA bypass and aortic endograft into the mid-descending thoracic aorta. The patient stabilized and was successfully discharged home.     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Endovascular Repair of a ruptured abdominal aortic and iliac artery aneurysm with an acute iliocaval fistula secondary to lymphoma

Abdominal aortic aneurysms (AAA) are common and generally asymptomatic unless rupture occurs. A 3 to 4-cm AAA has a 1-2% risk of rupture over 5 years. We present the case of an 85-year-old male with a history of chronic lymphocytic leukemia, a 3-cm infrarenal AAA, and a 2-cm right common iliac artery aneurysm whose AAA ruptured and who developed an acute iliac artery–to–vena cava fistula secondary to eroding adenopathy from an aggressive low-grade lymphoma. Initially, an open repair was attempted but access to the aorta was not possible because of complete encasement of the infrarenal and suprarenal aorta with tumor that was clinically invading the aortic wall. Secondary tumor invasion into the aorta is a rare complication. An endovascular repair was accomplished with successful exclusion of both the aneurysm and the iliocaval fistula. Endovascular repair provides a valuable alternative in the "hostile abdomen" when standard open repair may be hazardous or impossible.