A repair of the aortic pseudoaneurysm after ascending aortic grafting in acute type A dissection--a case report

A postoperative pseudoaneurysm of the ascending aorta is reported. The patient was a 73-year-old female with a history of graft replacement of the ascending aorta for acute type A dissection 5 years ago. She was referred to our hospital because of chest pain. Preoperative radiographic examination revealed a large pseudoaneurysm of the ascending aorta close to the distal anastomotic site of the graft as well as an aneurysm of transverse arch. During surgery, the pseudoaneurysm originated from a intimal defect in the aortic wall 1 cm distal to the suture line. It is suggested that the pseudoaneurysm was caused by a clamp injury during the initial operation. Replacement of the ascending aorta and transverse arch was successfully performed under selective cerebral perfusion. We should keep the clamp injury in mind when we apply an aortic clamp to a fragile dissected aorta.     

Repair of the aortic arch with fibrin glue in type A aortic dissection

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preliminary clinical results of surgery for type A acute aortic dissections using gelatin-resorcin-formaldehyde glue

We used gelatin-resorcin-form-aldehyde (GRF) glue to fuse the false lumen of type A acute aortic dissection in four patients. All were operated on within 3-24 hours after onset, and gluing of the two cylinders of the dissecting aorta could be done safely in a short time. Initial intimal tears were located in the transverse aorta in three patients and in the proximal descending aorta in one. Simple transection and end-to-end anastomosis of the ascending aorta was done for the first two cases. But in the last two patients, we resected the intimal tear in the transverse aorta and applied GRF glue to the stump of the aortic arch and to that of the aortic root, followed by graft replacement of the ascending aorta. There were no hospital deaths. But we had to reoperate on one patient five months after the first operation due to potentially residual dissection in the aortic root. GRF glue is a very useful adhesive for acute aortic dissection operations, but further refinement of the operative technique using it is necessary.     

Reoperation after repair of type A and B dissecting aneurysm

BACKGROUND: In the late postoperative period after repair of an aortic dissection or dissecting aneurysm, reoperations may be required. The interval to reoperation, size and location of intimal tear, and results of reoperation were evaluated. METHODS: Between January 1982 and April 1997, 138 patients underwent surgery for Stanford type A (90 patients) or type B (48 patients) dissections of the aorta. The entire aorta was evaluated in postoperative follow-up by computed tomography and magnetic resonance imaging for 6 months to 15 years. Reoperations were performed in 14 (10.1%) patients with changes in the aneurysms at the site of the initial repair or in the distal aorta. Selective cerebral perfusion or retrograde cerebral perfusion with deep hypothermia was used in the repair of the ascending, arch, and distal arch aneurysms. Reoperations included aortic root reconstruction (n=3), resection of a pseudoaneurysm (n=1), and replacement of the ascending aorta (n=1), arch (n=5), descending aorta (n=2), thoracoabdominal aorta (n=1), or abdominal aorta (n=1). Secondary reoperations were performed in four patients (replacement of the arch [n=2], thoracoabdominal aorta and abdominal aorta). Consequently two patients had subtotal aortic replacements. The aneurysms were caused by an anastomotic leak, a new intimal tear following aortic cross-clamping, a second intimal tear in the distal arch or abdominal aorta, and Marfan syndrome. RESULTS: Two patients (2/18 11.1%) died of bleeding or low output syndrome. Two patients died of graft infection or prosthetic valve infection 3 months after surgery respectively. CONCLUSIONS: 1) The surgical results of reoperation for type A and B dissections were good. 2) Close postoperative follow-up of the patent false lumen in the entire aorta was necessary. 3) At the initial operation, total resection of the intimal tear in the aortic arch in low-risk patients reduced the risk of reoperation.     

An early recrudescent case of Stanford type A closing aortic dissection

A 81-year-old female was hospitalized with chest discomfort. Findings of CT scan revealed Stanford type A acute aortic dissection, but the dissecting lumen had already closed with thrombus. Aortogram showed no intimal tear, intimal flap or ulcer like projection. Under the diagnosis of "closing aortic dissection", conservative treatment was selected. The dissecting lumen was disappearing gradually, but she had a sudden chest pain on hospital day 4 and CT scan demonstrated an enlarged and enhanced dissecting lumen. She underwent an emergency operation and a hemiarch replacement was performed successfully. Her postoperative course was uneventful and she was discharged from the hospital in good health.     

Ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade: report a case]

The ruptured thoracic aortic aneurysm has had severely high mortality. A 71-year-old male who suddenly fainted away was admitted to our hospital. He was in shock on arrival. Computed tomography and echo cardiogram demonstrated ruptured aortic arch aneurysm with hemorrhagic cardiac tamponade. Aortic arch replacement was performed using the selective cerebral perfusion under deep hypothermia. The recovery of his consciousness was delayed, and he had right hemiplegia postoperatively, but his state was improved gradually. Finally he complained only slight degree of aphasia, paralysis. An immediate and aggressive emergency operation is a only method to salvage the patient who has ruptured aneurysm of the thoracic aorta.     

Intramural hematoma of the thoracic aorta: precursor sign to thoracic aortic dissection

A 60-year-old man was admitted at his local hospital for persistent chest pain and suspicion of aortic dissection. No evidence of aortic dissection or intimal disruption was noted by means of computed tomography and transesophageal echocardiography. A localized intramural hematoma of the ascending aorta was found. He was first treated medically and remained asymptomatic for 8 days when he developed a new episode of chest pain. He was found to have an acute type A dissection by computed tomography. He underwent graft replacement of the ascending aorta and had an uneventful post-operative course. This case report describes the development of true aortic dissection in a patient who previously had a localized intramural hematoma.     

A surgical case of acute three-channeled aortic dissection in Marfan syndrome

We surgically treated a 35-year-old male with acute 3-channeled aortic dissection in Marfan syndrome. He had acute type A aortic dissection, and underwent Bentall's type operation, simultaneous graft replacement of the ascending aorta and total aortic arch. Pain recurred 5 years and 9 months after the first operation. CT scan showed two adjacent false lumens in the descending aorta. The morphology of the first and second dissections was Stanford type A + B. The second dissection was acute. In the second false lumen, a re-entry formation was observed in the abdominal aorta. Because severe pain was persistent, we immediately replaced the descending aorta using a femoro-femoral partial cardiopulmonary bypass. The patient was doing well and was discharged. When pain recurs in a Marfan patient with an aortic dissection, a 3-channeled aortic dissection should be suspected, and we recommend emergency surgery.     

A case of type A dissecting aneurysm who are complicated by paraplegia at the 4th day after emergent operation

The 62-year-old man was admitted to our hospital with chief complaints of chest and back pain. He was diagnosed type A acute dissecting aneurysm by chest computed tomography, and underwent urgent operation, replacement of the ascending aorta and resuspension of the aortic valve. He was recovered without any neurologic complications. However, he was complicated by paraplegia at the 4th postoperative day. We suspect that is due to early thrombotic occlusion of the false lumen where the anterior spinal arteries branch by the operation.     

Successful surgical repair of acute DeBakey type I aortic dissection complicated by acute occlusion of the suprarenal abdominal aorta

We reported a case of acute DeBakey type I aortic dissection presented with occlusion of the suprarenal abdominal aorta, who was successfully treated by simultaneous graft replacement of the ascending aorta and total aortic arch. The patient was a 68-year-old man who complained of chest pain and symptoms of acute arterial occlusion of bilateral lower extremities, and who had consciousness disturbance due to stroke caused by aortic dissection. He underwent simultaneous graft replacement of the ascending aorta and total aortic arch under selective cerebral perfusion during an emergent operation. For reconstruction of the arch vessels, we used three separate grafts that were connected to the aortic prosthesis before use. Although postoperative course was complicated by myonephropathic metabolic syndrome, the patient subsequently recovered and was discharged on foot. Early vascular reconstruction and appropriate management of reperfusion injury are extremely important in the setting of malperfusion phenomena complicating acute aortic dissection.     

A case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm

We report a rare case of Stanford type A acute aortic dissection associated with a distal aortic arch atherosclerotic aneurysm. A 71-year-old female was referred to us with the diagnosis of thrombosed Stanford type A acute aortic dissection, however on the next day transesophageal echocardiography revealed the false lumen has been recanalized. In the operation, there was a distal aortic arch atherosclerotic aneurysm which was unidentified at the preoperation. It is very rare that the dissection originated from atherosclerotic aneurysm and proceeded to proximal and distal portion of the aorta.     

Rupture of the aortic arch due to bacterial aortitis--a case report of a patient undergoing successful surgical therapy

A 59-year-old man came to our hospital because of hoarseness and chest pain. On initial examination, a chest roentgenogram showed no abnormality. Three weeks later, while the patient was waiting to undergo a computed tomographic (CT) scan, shock suddenly developed. A chest roentgenogram revealed an extremely wide mediastinal shadow. A CT scan revealed rupture of the aortic arch near the base of the left subclavian artery, although there was no aneurysm. An emergency operation was performed. The ruptured aortic arch was replaced with an artificial graft during cardiopulmonary bypass with selective cerebral perfusion. A diagnosis of infectious aortitis was not made until a pathologist discovered colonies of gram-positive cocci in the resected specimen of the aortic arch. Postoperatively, antibiotics were administered for only four days. The patient is well about two years after the operation. Infectious aortitis had a very low prevalence and rarely involves the thoracic aorta. However, we should be aware of that it may cause aortic rupture even in the absence of aneurysmal dilatation.     

Antiatherogenic effect of estrogen abolished by balloon catheter injury in cholesterol-clamped rabbits

The purpose of this study was to investigate the importance of an intact endothelial cell layer for the direct antiatherogenic effect of estrogen on the arterial wall. Thirty rabbits were bilaterally ovariectomized and subjected to mechanical injury of the endothelium by balloon catheterization of the upper thoracic aorta. Immediately after the operation, treatment was initiated with either 17 beta-estradiol or placebo given intramuscularly. All rabbits were clamped at a similar plasma cholesterol level from 1 week before the operation until the experiment was terminated 13 weeks later. In the undamaged aorta, ie, the aortic arch, the lower thoracic aorta, and the upper abdominal aorta, the estrogen-treated rabbits had one third (P = .06), one sixth (P = .002), and one seventh (P = .001), respectively, the accumulation of cholesterol of the placebo-treated rabbits. In the upper thoracic aorta that had been subjected to mechanical injury of the endothelium, however, aortic cholesterol accumulation was not significantly different between the two groups. Similar results were obtained by histological evaluation of the aortic tissues. Immunohistochemical staining with antibodies against macrophages, smooth muscle cells, and T lymphocytes revealed no significant differences in the intimal distribution of cells between estrogen- and placebo-treated rabbits, except for a higher number of T lymphocytes per unit intimal area of the undamaged aortic arch (P < .0005) in the estrogen-treated-rabbits than the placebo-treated rabbits. This is the first study to demonstrate that the antiatherogenic effect of estrogen is abolished by balloon catheter injury in cholesterol-clamped rabbits. These results may indicate that an intact endothelial cell layer is crucial for the direct antiatherogenic effect of estrogen on the arterial wall.     

Early and late results of replacement of the ascending aorta and/or aortic arch using selective cerebral perfusion

From 1987 to 1994, 116 patients received replacement of the ascending and/or aortic arch using selective cerebral perfusion. They were 82 male and 34 female, with average age of 64 years. There were 63 dissecting and 53 true aneurysms. Extent of replacement was: ascending aorta in 13, aortic root in 2, aortic arch in 93, and aortic root and complete arch in 8. Aortic arch replacements were composed of: 29 partial proximal aortic arch replacements, 44 complete aortic arch replacements, and 20 partial distal aortic arch replacements. Nineteen (16.4%) hospital deaths occurred. Univariate testing of pre-, intra-, and post-operative variables followed by stepwise logistic regression analyses identified elderly, ischemic heart disease, postoperative neurologic complication, cardiac dysfunction, renal failure, and massive bleeding as factors having independent association with hospital mortality. Neurologic complication was found in 10 patients (8.6%), and risk factor for this complication was preoperative peripheral vascular disease. Follow-up of hospital survivors documented an overall cumulative 5-year survive rate of 69%. There was no significant difference between dissection and true aneurysms in 5-year survive ratios, which were 63% and 82%, respectively. During follow-up periods, 18 patients died. Half of these cases were vascular deaths, caused by rupture, sudden death and secondary operation. Univariate analyses followed by stepwise Cox testing indicated that chronic obstructive pulmonary disease and a history of postoperative massive bleeding were associated with decreased later survival. Our experience suggests that selective cerebral perfusion is a safe technique for the repair of ascending aorta and/or aortic arch problems. High-risk subgroups of patients with these aortic problems can be identified by risk factors. Aggressive and careful management is necessary for such subgroups to improve early and late survival rates.     

National survey of radionuclide gastric emptying studies

The optimal surgical approach for complex aortic coarctation or an interrupted aortic arch with associated intracardiac defects is not universally agreed upon. We reviewed our experience with 18 consecutive patients (10 with coarctation, 8 with interrupted aortic arch) undergoing a 1-stage repair through median sternotomy between September of 1995 and February of 1997. Age at operation ranged from 3 days to 3 months (mean 23 days) and weight ranged from 1,700 g to 5,100 g (mean 3,350 g). Under hypothermic circulatory arrest, the aortic arch was reconstructed using native tissue-tissue anastomoses, and coexisting intracardiac anomalies were repaired by standard techniques. All patients survived the procedure and were ultimately discharged from the hospital. There were 2 late deaths in the interrupted aortic arch group, 1 during reoperation for subaortic stenosis and the other from noncardiac causes 5 months after discharge. Another interrupted aortic arch patient required a Ross-Konno procedure 8 months later. There has been no recoarctation among the 16 survivors. Thus a 1-stage repair for complex aortic arch obstruction in neonates can be accomplished with low operative risk, although long-term outcome is strongly influenced by the presence of subaortic obstruction.     

Aortic intimal sarcoma with acute myocardial infarction

An autopsy case of aortic sarcoma who died of acute myocardial infarction caused by coronary involvement is reported. The patient was a 54 year old woman who was admitted because of an undiagnosed fever and general fatigue of 6 months duration. Magnetic resonance imaging (MRI) showed a tumor in the aortic arch. Total aortic arch replacement was performed. It was diagnosed as a malignant mesenchymal tumor of the aorta. The patient died of acute myocardial infarction 10 months after the operation. At autopsy, the tumor had invaded the luminal surface and intima of the proximal anastomosis (the remnant ascending aorta and the graft), the aortic valves, the distal anastomosis (surgical line of the thoracic aorta plus the graft), and the coronary arteries. The left main coronary artery showed complete obstruction by fibrin thrombus with tumor invasion in the intima, which was responsible for acute myocardial infarction. Primitive and bizarre tumor cells proliferated with many slit-like tissue spaces. Most of the tumor except for its luminal surface showed necrosis. Ultrastructurally, there were spaces between tumor cells, suggesting lumen formation, and some of them had microvilli. This sarcoma was considered to be the so-called aortic intimal sarcoma.     

A surgically treated case of saccular true aneurysms in the ascending aorta

A surgically treated case of saccular true aneurysms in the ascending aorta caused by cystic medial necrosis is reported. A 59-year-old woman, who had no findings of Marfan syndrome, was admitted to our hospital because of chest discomfort and dyspnea on exertion. Echocardiography showed that massive pericardial effusion and the dilated ascending aorta without dissection. No aortic valve insufficiency nor dilatation of the Valsalva's sinuses were found out. Chest CT scan and aortography also revealed that focal dilatation of the ascending aorta without the intimal flap and the false lumen. Because of the presence of cardiac tamponade, we performed an emergency operation without definite diagnosis of the ascending aortic lesion. Intraoperatively, 2 saccular aneurysms, which were 55 x 45 x 20 mm and 25 x 15 x 15 mm in size, were found out in the ascending aorta. The ascending aorta was replaced with a woven Dacron graft successfully. These aneurysms were histologically diagnosed as true aneurysms caused by cystic medial necrosis. Although saccular true aneurysms of the ascending aorta are rarely observed, they should be considered as one of ascending aortic diseases that cause cardiac tamponade potentially.     

Successful graft replacement of the descending aorta after an extended reconstruction of the ascending and transverse aorta in a patient with Marfan's syndrome

A 27-year-old man with Marfan's syndrome underwent a total aortic graft replacement in three separate stages. Initially the abdominal aorta was replaced, followed by the ascending aorta and aortic arch, and finally the residual portion. The extensive reconstruction of both the ascending and transverse aorta at the second operation, even though no dissection was present in the aortic arch, reduced the risk of the subsequent operation since the same surgical approach did not have to be used.     

A case report of infective endocarditis with total rupture of the posterior papillary muscle after aortic valve replacement

We reported a case with severe mitral regurgitation caused by total rupture of the posterior papillary muscle two days after aortic valve replacement. A 62-year-old man was transferred to our hospital with high fever and dyspnea with severe aortic regurgitation caused by infective endocarditis. The left heart failure occurred suddenly two days after the initial operation. Echocardiogram revealed massive mitral regurgitation and rupture of the posterior papillary muscle. He underwent emergent mitral valve replacement. Histological examination of the papillary muscle showed typical ischemic necrosis without inflammation. The postoperative course was uneventful. We suggested the papillary muscle rupture in this case may be due to coronary artery emboli occurred in association with infective endocarditis.     

Surgical treatment of an aortic arch aneurysm: reports of 2 cases with lesion of the arch vessels

A 48-year old woman underwent surgery for an aortic arch aneurysm with stenosis or dilatation of three arch vessels caused by aortitis syndrome. Total arch replacement and reconstruction of three arch vessels were performed with hypothermic selective cerebral perfusion (SCP). To avoid atheroembolism and malperfusion to the brain, the rt. common carotid artery was perfused via the rt. subclavian artery through the dacron vascular graft and the lt. subclavian artery was cannulated and perfused distally to stenosis. A 65-year-old man who had an atherosclerotic aortic arch aneurysm with severe stenosis of the brachiocephalic artery underwent operation. In the operation, extracorporeal circulation was instituted with the arterial return through the lt. subclavian artery. Same as case 1, total arch replacement and reconstruction of three arch vessels were performed under hypthermic SCP. In this case, the left common carotid artery was transected and cannulated directly into the vessel, instead of cannulation through the aortic lumen because of atheromatous plaques in the orifice of the left common carotid artery. The patients recovered uneventfully and doing well now.