Veno-venous extracorporeal lung assist with concurrent distal aortic perfusion: repair of ruptured aorta in a patient with dense ARDS

Extracorporeal lung assist (ECLA) allowed surgical repair of a ruptured descending thoracic aorta to be performed in a patient with profound respiratory failure. Dense acute respiratory distress syndrome (ARDS) developed during his 15-day hospitalization at a regional trauma center. After transfer to a Level I facility, an additional injury was diagnosed: traumatic rupture of the aorta, contained within a pseudoaneurysm. ECLA by the veno-venous route was required immediately preoperatively and distal aortic perfusion was performed during the aortic repair. Despite deflation of the left lung, the patient was oxygenated and ventilated adequately during surgery. Cross-clamp time was 48 minutes. The patient was weaned from ECLA by the fifth postoperative day. To our knowledge, this is the first report of concurrent veno-venous pulmonary support with distal aortic perfusion.     

A case report: successful treatment of acute type B aortic dissection with renal and leg ischemia

A 56-year-old patient of acute type B aortic dissection with renal and leg ischemia successfully underwent emergency replacement of the descending thoracic aorta. Prior to this operation, we reperfused the ischemic legs in a controlled manner using a cardiopulmonary bypass circuit. This controlled limb reperfusion method could reduce reperfusion injury. Postoperatively, the patient also suffered from renovascular hypertension due to stenosis of the right renal artery. Renal stent angioplasty, performed 10 days after the operation, stabilized his blood pressure. Controlled limb reperfusion and renal stent angioplasty may be useful for managing branch complications associated with aortic dissection.     

A case of complete circumferential aortic rupture due to blunt chest trauma

A case of complete circumferential rupture of the thoracic aorta due to blunt chest trauma is presented. A 30-year-old man was admitted after a traffic accident. The admission chest X-ray film demonstrated mediastinal widening. About 6 hours after the traffic accident, chest CT scanning demonstrated mediastinal hematoma, left pleural effusion and partial aortic dissection. Diagnoses of aortic rupture and liver injury were made, and surgery for the thoracic aorta was performed immediately. The aorta was found to be completely disrupted for the length of 2 cm, and a vascular prosthesis was interposed between the two ends of the aorta under partial cardiopulmonary bypass. We conclude that the enhanced chest CT scanning is helpful for diagnosis, and that if other organ injuries are not severe, the emergency operation should be performed.     

Successful treatment of exsanguinating aortic injury from a fractured rib

A 57-year-old man presented in shock after a 15-foot fall from a ladder. A massive left hemothorax was present. He underwent prompt thoracotomy and was found to have a penetrating injury of the descending thoracic aorta caused by a fractured rib. Successful management of this type of aortic injury has not been previously reported.     

Traumatic rupture of the aorta. A five-year experience

In the five-year period ending in October, 1975, 31 consecutive patients with traumatic rupture of the thoracic aorta underwent surgery at the University of Maryland Hospital or the Maryland Institute for Emergency Medicine. All cases were confirmed by preoperative aortogram. Rupture was confined to one or more sites in the descending thoracic aorta at or distal to the origin of the left subclavian artery. The age was a mean of 26 years. Operation was done within an average of 18 hours after injury. Significant nonthoracic injuries were present in every case. Six patients with positive findings on peritoneal lavage underwent exploratory laparotomy prior to thoracotomy because of shock. Surgical repair was done by use of left heart bypass in 2 cases (one death), a passive aorta-aorta shunt in 23 cases (5 deaths), and without shunt or bypass in 6 cases (no deaths). An end-to-end tubular Dacron graft was used to reconstruct the aorta in all but one patient. Over-all survival rate was 25 of 31 patients (81 per cent). Paraplegia developed in one patient and renal failure in 3 patients (2 deaths) in the aorta-aorta shunt group. Hypertension was present in 18 (72 per cent) of the survivors. Palsy of the left recurrent laryngeal nerve persisted in 8 (32 per cent) of the survivors. Two of the deaths were related to technical problems of the shunting procedure and 2 to intrapleural exsanguination before proximal aortic control could be achieved. Complications and blood loss were reduced in the group with no shunt. The series lends support to the rigorous aortographic search for ruptured thoracic aortas in trauma patients with widened mediastinum. Once experience has been gained with shunting techniques, tears of the descending thoracic aorta may be safely repaired without shunt if done expeditiously.     

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.     

Rupture of a dissecting aneurysm into the superior vena cava in Marfan's syndrome

Aneurysmal dilatation of the aorta with subsequent dissection or rupture occurs frequently in patients with Marfan's syndrome. These complications are among the major causes of death. We report the case of a 51-year-old man with annulo-aortic ectasia in Marfan's syndrome. Acute aortic dissection and rupture into the superior vena cava occurred 8 years after aortic valve replacement. The preoperative diagnosis was made by right heart catheterization and computed tomography. A markedly increased left-to-right shunt occurred with rapid enlargement of the fistula due to the fragility of the aortic wall characteristic of Marfan's syndrome. Postmortem examination demonstrated severe medial necrosis with rupture of the aortic wall into the superior vena cava which was adherent to the suture line of the aortotomy from the previous surgery. Type A aortic dissection with severe congestive heart failure strongly suggested rupture into the pulmonary circulation.     

Successful aorto-circumflex coronary bypass grafting through left thoracotomy following aortic and mitral valve replacement

We report successful descending thoracic aorto-circumflex coronary artery bypass grafting using a saphenous vein graft through left thoracotomy in a 44-year-old female. The patient developed severe angina attack after aortic and mitral valve replacement. Coronary angiography showed 99% stenosis of the circumflex coronary artery. Under general anesthesia, left femoral vein to arterial partial cardiopulmonary bypass was performed via left 4 th intercostal space. Body temperature was lowered to 22 degrees centigrade, and spontaneous cardiac fibrillation occurred. After minimal exposure by pericardial dissection of the circumflex coronary artery, distal anastomosis and then proximal anastomosis at the descending thoracic aorta was carried out under cardiac fibrillation. This surgery was done with minimal intra-and postoperative bleeding. Postoperative course was very smooth, and the patient was discharged and leading a normal life for 6 months after surgery.     

Early and late outcome of operated and non-operated acute dissection of the descending aorta

OBJECTIVE: At present debate continues concerning the optimal mode of treatment for type B dissections. Controversies are mainly due to discordant results regarding survival following medical or surgical treatment. We assessed early and long-term outcome of acute dissection of the descending aorta treated by emergency aortic replacement, medical treatment or delayed surgery. METHODS: Between 1980 and 1995, 225 patients were hospitalized in the medical or surgical department of our institution with the diagnosis of acute type B aortic dissection. A total of 38 patients (16.8%) underwent replacement of the descending aorta within the first week after hospital admission. Primary indications for immediate surgery were: rupturing aneurysm (n = 15), diameter of the descending aorta (n = 13), malperfusion of the thoracoabdominal aorta (n = 8) and pseudocoarctation syndrome with uncontrollable hypertension (n = 2). All other patients (n = 187) underwent primary conservative treatment on the intensive care unit, including appropriate anti-hypertensive medication. In 12 of them, surgery was denied because of age or significant concomitant diseases. RESULTS: Hospital mortality after urgent or emergency surgery was 21% (8/38 patients) for the overall time period. There has been a significant decrease in hospital mortality during the last 5 year-period (12% versus 30% between 1980 and 1994). Causes of death were: cardiac failure in 3, bleeding complications in 2, postoperative mesenteric ischemia in 2 and septicemia in one patient. From the 30 operative survivors, 9 (30%) patients required further surgery on the native aorta after a mean follow-up of 48 +/- 13 months. Hospital mortality during conservative treatment was 17.6% (33/187 patients). Main causes of death were rupture in 14, thoraco-abdominal malperfusion in 13 and cardiac failure in 3 patients, whereas in 3 patients, the cause of death could not be evaluated. In this group, 9 patients had to be shifted to early surgery during the initial hospitalization because of impending rupture (n = 4), rapidly increasing diameter (n = 2) and suspicion of intestinal ischemia (n = 3). After hospital discharge, surgery for chronic dissection was performed in 47 patients, mainly because of expanding descending aortic aneurysm. Hospital mortality was 8% (4/47 patients). Actuarial survival rates after surgery during the first admission were 85 +/- 6% at 5 years and 61 +/- 8% at 10 years, versus 76 +/- 5 and 50 +/- 7% respectively, following conservative treatment (P < 0.001). CONCLUSION: Nowadays, acute type B dissection can be treated surgically with a reasonable perioperative risk. Despite aggressive anti-hypertensive treatment, hospital mortality of primary conservative treatment is still high and a substantial percentage of patients requires surgery during initial hospitalization. Main causes of death in both groups are rupture and abdominal malperfusion: therefore, closed clinical and radiologic assessment of the whole thoraco-abdominal aorta is of utmost importance. Long-term results are satisfying; unlimited radiographic follow-up allows for detection of potential severe complications and for proper planning of elective reoperations when indicated.     

A patient with aortic dissection and abdominal aortic aneurysm with fistula

Aneurysm of the abdominal aorta is not uncommon in later life. The frequency of aneurysm rupture varies with aneurysm diameter. In rare cases, the aneurysm may rupture intra-abdominally into surrounding structures and give rise to a fistula. When blood vessels are involved, the commonest form is aortocaval fistula, the presenting symptoms being those of severe right-ventricular heart failure. Although thoracic aorta dissection may be made manifest in acute intense chest pain, it is asymptomatic in up to 50 per cent of cases. The article consists in a case report of asymptomatic thoracic aorta dissection occurring concomitantly with a ruptured abdominal aneurysm the symptoms of which were severe right ventricular heart failure due to an aortocaval fistula causing increased pressure, and severe bilateral oedema of the legs. If the rare complication of an aortocaval fistula could be detected earlier, it might be possible to prevent progression to refractory cardiac failure. The possibility of a fistula should be borne in mind if haematuria is present in a case of abdominal aneurysm or a pulsatile abdominal mass is present in conjunction with a murmur.     

Surgical treatment of aortic rupture by blunt chest trauma

During a ten-year period, seven patients with traumatic rupture of the thoracic aorta were operated upon. Four patients of them were operated within one week. Chest X-rays and chest computed tomography could not always reveal the exact diagnosis of aortic rupture. Intravenous digital subtraction angiography was useful to confirm the diagnosis. The repair of the rupture was accomplished with the adjunct of left heart bypass using Bio-pump, which was useful to reduce the bloodloss with a limited systemic heparinization. Another three patients were diagnosed to have chronic post-traumatic aneurysm of the thoracic aorta and underwent aortic replacement with prosthetic graft. One of seven patients died at seventh postoperative day because of cerebral contusion, the associated lesion of an automobile accident. It is stated that the aortic rupture is immediately fatal in approximately 80% of individuals, and most of remaining 20% die within 2 weeks unless the lesion is repaired. Therefore immediate operative intervention is recommended when the aortic rupture is strongly suspected. Chronic post-traumatic aneurysms should be resected because it has become apparent that the majority of patients with this lesion will develop complication, such as sudden rupture.     

Large-scale screening for factor V Leiden mutation in a north-eastern German population

A 37-year-old man was referred with thoracic pain after a deceleration trauma. He also had a cerebral contusion and a wrist fracture. There were no sings of hypovolemic shock. Computerized tomography (CT) of the chest and transoesophageal echocardiography (TEE) demonstrated a type B aortic dissection originating just distal to the left subclavian artery. There was a patent false lumen without rupture or distal ischaemia. Conservative treatment was given. A paralytic ileus developed and abdominal complaints persisted for several months. Angiography showed normal patency of mesenteric vessels. On follow-up, 3 years after the accident a slight aortic dilation was found on CT thorax without development of a post-dissection aneurysm. Blunt thoracic injury to the aorta usually gives rise to aortic rupture in the region of the isthmus, which can be complete or partial. In the latter case a false aneurysm may develop. An intimal tear after blunt trauma leading to type B aortic dissection rarely occurs. General principles regarding treatment of type B dissection also apply to this particular condition.     

Combined surgery for coronary artery disease and thoracic aortic disease

Combined surgery in 6 cases who had coronary artery disease and thoracic aortic disease simultaneously was analyzed. Case # 1 had ascending aortic replacement under deep hypothermic circulatory arrest because of iatrogenic aortic dissection caused by aortic clamp during the routine coronary artery bypass grafting (CABG). Case # 2 had DeBakey type II chronic dissection. Case # 3 had type I aortic dissection 4 years after the initial CABG. Both case # 2 and # 3 had ascending aortic replacement under retrograde cerebral perfusion along with CABG. Transverse aortic replacement was performed in case # 4, # 5 and # 6 under selective cerebral perfusion along with CABG. Case # 4 was associated with ascending-transverse aortic aneurysm. Case # 5 had aortitis syndrome complicated with severe coronary ostial stenosis and cervical branch stenosis. Case # 6 also had aortitis syndrome, severe coronary ostial stenosis, heavily calcified ascending-transverse aorta, and mitral and aortic regurgitation. This case had mitral and aortic valve replacement additionally. Case # 2 died of low cardiac output syndrome and multi-organ failure postoperatively. Case # 4 did not recover from profound shock that followed the preoperative acute myocardial infarction. The problems of low cardiac output syndrome caused by long interval of ischemic cardiac arrest, and also the problems of proximal anastomotic site of saphenous vein grafts were discussed.     

Human papillomavirus-specific serologic response in vulvar neoplasia

We describe a case of positional dyspnea due to compression of the tracheobronchial tree by an extensive thoracic aneurysm. In a 77-year-old woman with long-standing systemic hypertension, intermittent anterior chest pain gradually developed over several years. She had no history of asthma or thoracic trauma. She was admitted to our hospital because of sudden, severe shortness of breath. The breathlessness was markedly worse when she lay on her back or on her right side. On physical examination, she was in acute respiratory distress with cyanosis, severe hypertension (180/110 mmHg), tachycardia, and inspiratory stridor. A chest X-ray film showed loss of volume and nearly complete radiopacity of the left hemithorax. Arterial blood gas analysis revealed an arterial oxygen partial pressure of 54.8 mmHg, a carbon dioxide partial pressure of 39.8 mmHg, and an oxygen saturation of 84.5 percent on room air. Computed tomographic examination of the thorax showed dilation of the aortic arch and descending aorta, and marked compression of the trachea and the left main bronchus. Examination with a fiberoptic bronchoscope revealed extrinsic compression of the trachea just proximal to the carina. The patient's symptoms stabilized. However, she did not undergo surgery because of her age and because of the size of the aneurysm. She died due to rupture of the aneurysm.     

Dysplastic nodules in cirrhotic liver: arterial phase enhancement at CT and MR imaging--a case report

BACKGROUND: The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital. METHODS: A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear. RESULTS: The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor. CONCLUSIONS: Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.     

Electronic access to mouse tumor data: the Mouse Tumor Biology Database (MTB) project

BACKGROUND: Single-stage extensive replacement of the thoracic aorta usually involves a period of circulatory arrest with performance of the graft-to-lower descending thoracic aorta anastomosis before performing the anastomosis to the arch vessels. To minimize the period of brain ischemia and reduce the potential for neurologic injury, we developed an alternative technique. METHODS: In 6 patients with extensive aneurysms involving the entire thoracic aorta, exposure was obtained via a bilateral thoracotomy in the anterior fourth intercostal space with transverse sternotomy. A 10-mm graft was anastomosed to the aortic graft, opposite the site of the planned anastomosis to the arch vessels. During a single period of circulatory arrest (34-46 minutes), the aortic graft was attached to a cuff of aorta containing the arch vessels. The graft was then clamped on either side, and the arch was perfused with cold blood for 20 to 36 minutes. After the distal aortic anastomosis was completed, antegrade perfusion was established via the 10-mm graft. The proximal aortic anastomosis was performed last. RESULTS: No patient sustained a permanent neurologic deficit. All 6 patients were discharged from the hospital. CONCLUSIONS: The "arch-first" technique, combined with a bilateral transverse thoracotomy, allows expeditious replacement of the thoracic aorta with an acceptable interval of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by establishing antegrade perfusion.     

Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention

Recurrent aortic aneurysms, persistent or new dissection, new onset of valvular and coronary artery disease, graft infection, and prosthetic endocarditis are not rare after thoracic aortic operations; they can be difficult to diagnose and represent a formidable surgical challenge. Between 1977 and 1991, 876 operations were performed on the thoracic aorta in our institution: 340 in dissections, 299 in true aneurysms, 150 for aortic remodeling and external wall support during aortic valve replacement, and 87 for miscellaneous causes. During the same period, there were 193 additional reoperations. Vascular reoperations on abdominal aorta and peripheral arteries accounted for 73 cases and are not further discussed in this study. The reasons for reoperation (n = 130) in 120 patients were: failure of biologic valves (n = 23); aneurysm recurrence in a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at suture lines (n = 13); new dissection or dilatation involving ascending aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10); aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n = 5); and new onset of coronary disease (n = 5). Infected aortic graft and prosthetic endocarditis accounted for 10 reoperations, and a planned two-staged procedure was performed in 6 patients. Omitting the failed biologic valves, reoperations were performed on the aortic segment previously operated on in 69.3% of the cases and on other thoracic segments in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A significant decrease in operative mortality was observed in the most recent period (3.0% between 1989 and 1991). Reoperations are technically demanding, and some of them are preventable; therefore (1) graft inclusion technique should be abandoned in ascending aortic operation due to formation of false aneurysms; (2) in patients with Marfan syndrome, complete repair of the diseased aorta should be attempted during the initial operation; (3) aortic arch dissection should be repaired definitively during the first operation in low-risk patients; (4) biological valves should be avoided in aneurysm operations; and (5) homograft replacement is the treatment of choice in prosthetic endocarditis or in infected composite graft after an aortic valve or ascending aortic operation.     

Aortic aneurysm complicated with coarctation of the aorta and Turner syndrome

A 23-year-old female with Turner syndrome and horse-shoe kidney underwent the operation of the coarctation of the aorta associated with the thoracic aortic aneurysm. The aortic aneurysm was located between the left carotid artery and the coarctation of the aorta, and the subclavian artery which was branched away from the aortic aneurysm was also aneurysmal. Aneurysmectomies and the reconstruction of the descending thoracic aorta and the left subclavian artery were performed with knitted Dacron grafts under assisting of the left atriodescending thoracic aortic bypass with Bio-pump. The disease was rare and such a case was not reported previously.     

Extension of the "elephant trunk" technique in complex aortic pathology: the "bidirectional" option

BACKGROUND: The "elephant trunk" technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the "bidirectional elephant trunk." This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch. METHODS: The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement. RESULTS: This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation. CONCLUSIONS: The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.     

Aortic sarcoma four years after Dacron graft insertion

Malignant fibrous histiocytoma of the aorta developed in a 70-year-old man 4 years after he had undergone repair of a type B aortic dissection with Dacron graft interposition. The tumor surrounded the graft externally and involved the adventitia of the aorta near the proximal anastomosis. Clinically and radiologically it mimicked a pseudoaneurysm of the descending thoracic aorta. Primary aortic sarcomas are extremely uncommon and only rarely reported in association with prior aortic graft insertion.