Related Articles

Surgical treatment of the combination of aneurysms of an aberrant right subclavian artery, distal aortic arch, and descending thoracic aorta requires control of structures in both the right and the left hemithorax. We report a 2-stage surgical approach. The 1st stage, performed through a median sternotomy, consists of an elephant trunk reconstruction and an interposition graft to the ligated aberrant right subclavian artery. The 2nd stage, performed through a left thoracotomy, is an interposition graft from the elephant trunk to the distal descending thoracic aorta.

We present the case of a 57-year-old woman who had an intramural hematoma of the ascending aorta and aortic arch. After initial blood pressure control and imaging studies, the patient underwent limited surgical repair that consisted of ascending aortic replacement. One week postoperatively, the aortic arch hematoma progressed to a full dissection that extended into the proximal descending aorta. Emergent aortic arch replacement was required.

Current world medical literature regarding thoracic aortic intramural hematoma is presented. This case supports the treatment of intramural hematomas of the ascending aorta and arch by surgical replacement of both segments with a Dacron graft, with the patient under deep hypothermic circulatory arrest. (Tex Heart Inst J 2003;30:325–7)

Management of extensive, chronic, dissecting aortic aneurysms after prior repair of the ascending aorta presents a technical challenge for surgeons. A symptomatic 64-year-old patient was admitted for elective surgical repair of an aortic annular dilatation, causing severe aortic regurgitation, and a Crawford type II extended thoracoabdominal aneurysm, 4 years after he underwent primary repair of an acute aortic dissection. The aorta was diffusely dilated, and there were no sites beyond the distal aortic arch where anastomosis could be performed. We successfully performed total aortic replacement with a 2-stage strategy, using an arch translocation technique and an intra-arch elephant-trunk technique.

A 67-year-old female patient was treated with conventional total arch replacement and insertion of a stented elephant trunk (SET) graft into the descending thoracic aorta for acute DeBakey type I aortic dissection at one time. She had been treated with right coronary artery stent insertion for acute myocardial infarct 4 days earlier, and at that time, she was diagnosed with acute DeBakey type I aortic dissection from the ascending aorta to the suprarenal artery based on trans-esophageal echocardiography and aorta computed tomography. Through a median sternotomy, we inserted the SET graft through the opened aorta to the descending aorta. We also performed anastomosis between the proximal stented graft and the distal aortic arch, and then performed total arch replacement. For acute DeBakey type I aortic dissection, we report total arch replacement with insertion of a SET graft as a combination of conventional surgery and the interventional technique.

Pseudoaneurysms of the ascending aorta after the original inclusion/wrap technique of the Bentall procedure present a difficult surgical management problem and are associated with substantial morbidity and mortality. Patients with Marfan syndrome frequently develop aneurysms and dissections that involve multiple aortic segments. We present the case of a Marfan patient who successfully underwent repair of a giant ascending aortic pseudoaneurysm and concomitant repair of an abdominal aortic aneurysm. An aggressive surgical strategy followed by life-long cardiovascular monitoring is warranted in order to prolong the survival of these patients. (Tex Heart Inst J 2003;30:233–5)

A 71-year-old patient was admitted for synchronous aneurysms of the aortic arch, brachiocephalic trunk, and juxtarenal abdominal aorta involving the iliac arteries. The patient first underwent open surgical repair of the juxtarenal abdominal aortic aneurysm by means of aorto-bifemoral bypass. Three months later, he underwent off-pump surgical repair of the aneurysm of the brachiocephalic trunk and bypass grafting from the ascending aorta to the brachiocephalic trunk and the left common carotid artery, followed by successful exclusion of the aneurysm of the aortic arch by deployment of a Zenith TX1 custom-made endograft, inserted through a limb of the aorto-bifemoral graft.

Combined endovascular and open surgical treatment is an appealing new alternative to open surgical repair for complex aortic diseases. Debranching of the aortic arch enables endovascular grafting in this area, thereby avoiding cardiopulmonary bypass and circulatory arrest. Staged and simultaneous procedures should be considered for the treatment of complex aortic diseases even in poor-risk patients; however, due to the investigative characteristics of these procedures, patient selection and postoperative follow-up should be carried out with utmost attention.

An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies. In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta. Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.

We propose a new cannulation and perfusion technique for aortic arch surgery, in order to achieve continuous antegrade total-body perfusion under moderate hypothermia.

The heart and the aortic arch are exposed through a median sternotomy. Cardiopulmonary bypass is established from the right atrium to the right axillary artery. At 26 °C of body temperature, the supra-aortic vessels are clamped, the ascending aorta and the aortic arch are incised, and a cuffed endotracheal cannula, connected to an arterial line geared by a separate roller pump, is inserted into the descending thoracic aorta. Perfusion is started in the distal body, while the brain is perfused through the right axillary artery. Once the aortic arch has been replaced with a Dacron graft and the supra-aortic vessels have been reimplanted on the graft, the arterial line in the descending thoracic aorta is clamped and removed. The supra-aortic vessel clamps are removed, the proximal part of the Dacron graft is clamped, and systemic cardiopulmonary bypass is resumed via the right axillary artery.

From January 2002 through December 2005, this technique was used in 12 consecutive patients on an emergency basis, due to acute aortic dissection that required total arch replacement. Within the first 30 postoperative days, 1 patient (8.3%) died, and no patient had permanent neurologic deficits.

This simple technique ensures a full-flow antegrade total-body perfusion during all phases of the surgical procedure, thereby eliminating ischemia–reperfusion syndrome and yielding excellent clinical results.

A thoracic aortic aneurysm (TAA) is a potentially life-threatening condition with structural weakness of the aortic wall, which can progress to arterial dilatation and rupture. Today, both an increasing awareness of vascular disease and the access to tomographic imaging facilitate the diagnosis of TAA even in an asymptomatic stage. The risk of rupture for untreated aneurysms beyond a diameter of 5.6 cm ranges from 46% to 74% and the two-year mortality rate is greater than 70%, with most deaths resulting from rupture. Treatment options include surgical and non-surgical repair to prevent aneurysm enlargement and rupture. While most cases of ascending aortic involvement are subject to surgical repair (partially with valve-preserving techniques), aneurysm of the distal arch and descending thoracic aorta are amenable to emerging endovascular techniques as an alternative to classic open repair or to a hybrid approach (combining debranching surgery with stent grafting) in an attempt to improve outcomes.

Summary

A 39-year-old man presented with acute headache and neck pain, followed by quadriparesis and quadriparesthesia, accompanied by urinary and bowel incontinence. Lumbar puncture showed subarachnoid haemorrhage. Angiogram via a right axillary approach revealed severe coarctation of the aorta, between the left common carotid artery and left subclavian artery. Multiple collateral circulation including an enlarged anterior spinal arterial axis bridging the stenosed arch provided collateral circulation to the abdominal aorta. A small lobulated aneurysm was seen at the radiculomedullary-anterior spinal artery junction from the right ascending cervical artery. This patient underwent successful surgical clipping of the aneurysm. Pathogenesis of the spinal arterial aneurysm associated with coarctation of the aorta is likely to result from the haemodynamic stress from collateral circulation through the anterior spinal axis rather than segmental arterial disease or angiodysplastic disease. Aneurysms of the spinal artery are rare but can be unusually found in association with SCAVMs, coarctation of aorta, Klippel-Trenaunay syndrome or more rarely with aortic arch interruption.

A saccular aortic arch aneurysm that is secondary to aortic arch coarctation and that is accompanied by a ventricular septal defect is a rare combination in the adolescent patient. Total simultaneous repair of all of these conditions is desirable, because of the higher morbidity and mortality rates of staged procedures—particularly when resection of the saccular aneurysm is delayed.

Herein, we discuss the case of a 16-year-old boy who underwent simultaneous surgical correction of these malformations. With the aid of cardiopulmonary bypass on the beating heart, the coarctation and the aneurysmal segment were resected, and a tubular Dacron graft was interposed. The ascending aorta and femoral artery were both then cannulated to ensure whole-body perfusion during cardiopulmonary bypass. The ventricular septal defect was closed with the patient under cardioplegic arrest. After 10 days, he was discharged from the hospital without sequelae. We conclude that single-staged repair of cardiac abnormalities and of an aortic arch aneurysm that is secondary to coarctation of the aortic arch can be performed safely and effectively in adolescent and adult patients by use of our technique.

Elective treatment of descending thoracic aneurysms involves direct surgery, with Dacron graft replacement of the diseased aortic segment. When the patient's condition contraindicates major surgery, however, the surgeon should consider using an extraanatomic approach—implanting an ascending aorta-to-abdominal aorta Dacron bypass graft in a ventral position and leaving the diseased segment undisturbed. After such a procedure, the descending thoracic aorta must be excluded from the normal circulation. For this purpose, we have designed an intraaortic occluding technique in which an umbrella-like device is implanted immediately distal to the left subclavian artery. This technique has proved safe and uncomplicated in canine experiments and is ready for clinical trials. (Texas Heart Institute Journal 1987; 14:196-205)

Images

Aortic rupture has a high mortality rate and can be considered a medical emergency. The standard treatment for aortic rupture is surgical repair. An aortic stent graft for a ruptured descending aorta is considered an effective alternative treatment. However, an aortic stent graft is difficult when the aortic aneurysm is in the aortic arch due to supra-aortic vessels. We report on a patient with a ruptured aortic arch aneurysm treated with a hybrid procedure, which involved a carotid to carotid bypass operation and an aortic stent graft. A 71-year-old male patient visited our cardiovascular center suffering from hemoptysis. The chest CT and aortography showed a 9 cm sized aortic arch aneurysm 0.5 cm distal to the left subclavian artery and a hemothorax in the left lung. The patient refused to undergo a full open operation. We performed a carotid to carotid bypass in advance, and two pieces of aortic stent grafts were placed across the left carotid artery and left subclavian artery. The follow up CT showed the aortic stent grafts, no endoleaks and no thrombus in the aortic arch aneurysm. The patient was discharged from the hospital without complication.

This report concerns a 29-year-old man with recent Streptococcus viridans endocarditis on a bicuspid aortic valve who was found to have a mycotic aneurysm of the left anterior descending coronary artery and infective erosion and thinning of the posterior wall of the ascending aorta 1.5 to 3.5 cm above the origin of the left coronary artery, a combination of lesions not previously reported. Mycotic aneurysm of the coronary arteries affects less than 1% of patients with infective endocarditis, and there are few reports of the management of these rare lesions. The surgical management of this patient is presented with a brief review of the available literature.

Images

Introduction

Current strategies for repair of descending thoracic aortic aneurysms consist of open repair with surgical graft replacement or thoracic endovascular aortic repair. We review and update our overall experience in aortic thoracic diseases and specifically analyzed our outcomes with thoracic endovascular aortic repair in patients with descending thoracic aortic aneurysms.

Methods

From 1993 to present a total of 1144 patients were treated in our Center for pathology involving the thoracic aorta. Since 1998, 322 patients underwent thoracic endovascular aortic repair, and among this group, in 188 cases the descending aorta was involved. In 74% of patients treated for a descending thoracic aortic lesion, a degenerative aneurysm was observed.

Results

In patients with descending thoracic aortic aneurysms receiving thoracic endovascular aortic repair, our technical success rate, i.e. deployment of endograft with complete exclusion of the lesion/minimal endoleak, was 99.5% (one case required emergent open conversion) with a perioperative mortality of 2.6% (five patients). The rate of spinal cord ischemia, manifesting either as paraplegia or paraparesis, was 4.7%. Delayed onset spinal cord ischemia ameliorated with adequate arterial pressure and cerebrospinal fluid drainage.

Conclusions

Our experience of selected patients undergoing thoracic endovascular aortic repair of descending thoracic aorta aneurysms is satisfactory with very low mortality and morbidity. A large use of thoracic endovascular aortic repair is foreseen in the next future.

OBJECTIVE

Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections.

METHOD

We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients.

RESULTS

The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1–56), and the survival rate was 77.8%. The endoleaks’ rate was 3.7% (1/27), due to a stent-graft migration.

CONCLUSION

Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

After cardiac transplantation, bacterial mediastinitis is a rare but dangerous early complication. Of the 113 patients who underwent heart or heart-lung transplantation at our hospital from August 1981 to April 1989, 8 developed purulent mediastinitis. Treatment involved surgical débridment, local irrigation, drainage, and high-dose systemic antibiotics. No patient died of an acute mediastinal infection. In 2 cases, however, chronic mediastinitis led to the formation of a huge mycotic aneurysm of the ascending aorta. Eleven days after surgical intervention for rupture, 1 patient died of aneurysmal rerupture; the 2nd patient remains well 16 months after prosthetic replacement of the ascending aorta and reconstruction of the necrotic proximal portion of the left coronary artery with a saphenous vein patch. (Texas Heart Institute Journal 1991;18:186-93)

Images

We report a case of ruptured mycotic aneurysm involving innominate artery requiring an urgent surgical treatment. A 62-yr-old woman presented with fever and dyspnea. Previously, she was diagnosed with colon cancer and received right hemicolectomy and one cycle of adjuvant chemotherapy. On echocardiogram, pericardial effusion was noted and emergency pericardiocentesis was performed. CT scan revealed aortic aneurysm involving ascending aorta and innominate artery, and thrombi surrounding those structures. Patch repair of the defect in the ascending aorta and ringed Goretex graft to bypass the innominate and ascending aorta were performed. We believe that this is the first case of ruptured mycotic aneurysm involving innominate artery.

Interrupted aortic arch is a rare condition, usually lethal in early infancy without treatment. The only characteristic feature on conventional non-invasive investigation is peripheral pulse inequality, which indicates ductal construction, and therefore may be absent or transient and preterminal. We report the cross-sectional echocardiographic findings in seven patients with aortic arch interruption between the left carotid and subclavian arteries. Their ages were 1 day to 7 months (median 7.5 days). The arterial connection was concordant in four, double outlet right ventricle in two, and truncus arteriosus in one. In each case the ascending aorta was small in comparison to the pulmonary trunk. From the suprasternal approach the ascending aorta could be seen to terminate in the left carotid artery, and the ductus to continue smoothly into the descending aorta, with no vestige of an aortic arch linking its ascending and descending portions. The left subclavian artery was seen to arise distal to the ductus in all but one patient. All four patients with ventriculoarterial concordance had pronounced subaortic stenosis caused by posterior displacement of the infundibular septum. Cross-sectional echocardiography therefore provides the only accurate method of non-invasive diagnosis of this condition. It permits early treatment with prostaglandins to prevent ductal closure, a planned approach to cardiac catheterisation, and a further means of investigating the nature of subaortic stenosis in this condition.

Images

While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

We report a case of abdominal aortic aneurysm complicated by retroperitoneal fibrosis with both duodenal and bilateral ureteral obstruction. The patient underwent successful bilateral transurethral ureteral stenting, and then he was referred for surgical treatment of the aneurysm. Massive retroperitoneal fibrosis was found at surgery, and the mass was removed along with the diseased aorta, which was replaced by a bifurcated Dacron prosthesis; duodenolysis and ureterolysis were concomitantly performed. Ureteral stents were removed on the 8th postoperative day. Follow-up assessment at 1 year showed normalization of the urinary tract structure at echography and good hemodynamic performance of the vascular prosthesis at Doppler examination. To our knowledge, no other case of duodenal and bilateral ureteral stenosis secondary to massive retroperitoneal reactive fibrosis in association with abdominal aortic aneurysm has been reported. (Tex Heart Inst J 2003;30:311–3)

We describe a 54-year-old man who had an ascending aortic prosthetic graft and a porcine aortic valve prosthesis that were infected by Candida albicans. This infection led to the formation of a dissecting false aneurysm of the remaining transverse and entire descending thoracic aorta, and the man was admitted to our hospital for surgical treatment in February of 1991. Staged in situ graft replacement was performed using Borst's "elephant trunk" repair for the proximal aortic reconstruction and an open distal anastomosis technique for the distal repair. Candida albicans in the residual prosthetic graft was identified, and therapy with high-dose liposomal amphotericin B was initiated. The use of liposomal amphotericin B reduces the incidence of adverse effects and allows administration of higher doses than those possible with conventional amphotericin B therapy. Lifelong antifungal therapy is recommended for patients with C. albicans infection of prosthetic aortic grafts.

Images

Endovascular grafts have been widely used for the treatment of aneurysms since the early 1990s. They are preferred especially for use in patients in whom conventional surgical methods carry high risks of death and morbidity. Increasing operator experience and technical refinements in endovascular grafting have enabled these procedures to be performed even in critical segments of the aorta, such as the thoracic and arch levels. In this report, we present the case of a patient who was treated successfully with an endovascular graft for a mycotic saccular aneurysm located just below the left subclavian artery.

We report a 72 year-old man with dysphagia and dizziness. Aortography and Computed tomographic scans revealed the aberrant right subclavian artery arising from a calcified aneurysm of the Kommerell's diverticulum and bilateral carotid artery disease with atherosclerotic narrowing. Surgical relief was accomplished by excluding the aneurysm from circulation through the aortic arch and a 10 mm graft was interposed between the aberrant artery and the ascending aorta.

The Seldinger technique is a method of femoral cannulation that has been used to establish cardiopulmonary bypass. Reports of cannulation of the ascending aorta for antegrade perfusion using the Seldinger method are anecdotal. To the best of our knowledge, the approach described herein for direct cannulation of the ascending aorta with use of the Seldinger technique for antegrade perfusion has not been previously described in the English-language medical literature. This method is helpful when the surgeon is treating a patient who has a calcified ascending aorta, complicated aortic dissection, calcified femoral vessels, or a diseased thoracoabdominal aorta. In such cases, retrograde perfusion has been associated with severe complications as a result of atheromatous embolization from the descending thoracic aorta.

Herein, we describe our approach to cannulation for cardiopulmonary bypass, which entails insertion of an aortic cannula into the ascending aorta by means of the Seldinger technique. A soft-tip guidewire is inserted through an arterial entry catheter that has been used to puncture a hole in the wall of the vessel. Then the aortic cannula is introduced into the vessel, sliding along the guidewire. Guided by transesophageal echocardiography, the tip of the cannula is positioned carefully and is then advanced into the descending aorta. This positioning of the cannula decreases the chance of arterial embolization, thereby improving cerebral protection. If cannulation of the ascending aorta is not feasible, the transverse aortic arch or proximal descending aorta can be used.