Local transverse arch repair for type A aortic dissection

BACKGROUND: The management of retrograde dissections originating from the transverse arch is controversial. Although replacing the ascending aorta is clearly beneficial, the appropriate approach to the management of the arch tear is not as apparent and ranges from no intervention to total arch replacement. METHODS: Three patients presented with acute (n = 2) or subacute (n = 1) aortic dissection, with tears involving the transverse arch. All underwent local transaortic pledgeted suture repair of the arch tears during hypothermic circulatory arrest, as well as graft replacement of the ascending aorta. RESULTS: Circulatory arrest times ranged from 12 to 15 minutes (transaortic arch repairs alone) to 48 minutes (transaortic arch repair and open distal graft anastomosis). Postoperatively all patients awoke within 12 hours and subsequently did well neurologically. CONCLUSIONS: In the face of a type A dissection with an entry in the transverse arch, local transaortic repair with concomitant ascending aortic replacement represents a viable middle ground between no arch intervention and lengthy arch replacement. Huge entry tears or aneurysmal arch enlargement would preclude such an approach.     

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.     

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.     

Long-term results of the surgical treatment of acute type A thoracic aortic dissection

Out of a population of 110 patients operated as an emergency for acute Stanford type A dissection of the thoracic aorta between 1985 and 1994, there were 84 survivors. Seventy-nine were assessed after a mean follow-up period of 47.3 months. The corrected 1 year, 5 year and 10 year survival rates were 69 +/- 5.1%, 53.1 +/- 6% and 42.1 +/- 7.1% respectively. There were 19 deaths during the study period: in two thirds of cases death was due to cardiovascular complications related to the aortic pathology or hypertension. There were 13 reoperations in 12 patients for complications on the initial site of repair or for progression of the pathological process. The average time to reoperation was 21.5 months with an operative mortality of 3 patients (25%). Predictive factors of reoperation were young age (52 +/- 4.4 years vs 60.1 +/- 1.4 years; p = 0.037), the persistence of a patent false lumen (p = 0.033) and the initial surgical techniques as the incidence of reoperation seemed to be higher after treatment with biological glue alone or resuspension of the aortic valve compared with replacement of the ascending aorta or Bentall's procedure (p = 0.08). The incidence of reoperation also varies with time as it was 1.8 +/- 0.7% at 1 year, 18.5 +/- 6.5% at 5 years and 26% +/- 7.8 at 10 years. In spite of improvements in surgical technique and postoperative care, acute type A dissection of the aorta carries a poor prognosis in both the short and the long-term with a notable number of cardiac or other complications related to repair of the initial aorta. Analysis of these and other reported results suggest that initial surgery should be as complete as possible with extension to the aortic arch when involved: this more aggressive attitude should improve the long-term results by reducing the risk of reoperation responsible for a high mortality rate.     

Early and late risk factors in surgical treatment of acute type A aortic dissection

A specific and saturable interaction between 125I-gastrin and eosinophils was discovered in autoradiographs of human gastric mucosal tissue and confirmed in isolated and enriched preparations of WBC's. Gastrin displaced 125I-gastrin from eosinophils in a dose-dependent manner with a D50 = 11 uM. Scatchard analysis of the saturation curve indicated a single binding site of low affinity (Kd = 4.14 uM) and high capacity (Bmax = 430 umoles/mg protein). The gastrin binding protein was localized to the granular core of the eosinophil and found to have a molecular weight of approximately 15 kDa following chemical crosslinking of radioligand to granules and SDS/PAGE. Based on its molecular weight and granular location and the charge characteristics of gastrin, the gastrin binding protein in the human eosinophil is most likely major basic protein. In vivo this interaction might act to limit the cytotoxic potential of MBP on tissues and/or attentuate gastrin concentrations thereby helping regulate gastric acid secretion and mucosal growth.     

Surgical treatment of acute type A aortic dissection with an intraluminal sutureless graft

The surgical treatment of acute type A aortic dissection remains a great challenge to all cardiac surgeons. From January 1991 to June 1993, 21 consecutive patients (13 men and eight women, aged 34 to 74 years) underwent emergency operations to repair acute type A aortic dissection, with the aid of hypothermic circulatory arrest. The intima tear was located in the ascending aorta in 13 patients, in the aortic arch in five patients, and in the descending aorta in three patients. The dissected ascending aorta was replaced with sutureless, intraluminal vascular grafts in all 21 patients. The intima tears in the aortic arch of five patients were primarily repaired. Modified Cabrol's shunts were created in seven patients for hemostasis, and Dacron grafts were used to wrap the ascending aorta in 18 patients. Retrograde cerebral perfusion during circulatory arrest was performed on 15 patients. The circulatory arrest time was 37 +/- 10 minutes (mean +/- SD). All patients survived the operation and regained consciousness in the early postoperative period without neurologic deficit. Post-treatment follow-ups (mean, 18.2 months) were completed in all patients except one, who died 12 months after the operation as a result of a traffic accident. All of the surviving patients are doing well without any further aortic operations. Our experience suggests that surgical repair of the acute type A aortic dissection can be a simple and safe procedure if sutureless intraluminal grafts are used and hypothermic circulatory arrest and retrograde cerebral perfusion are utilized.     

Surgical repair of type A aortic dissection by the circulatory arrest-graft inclusion technique in sixty-six patients

During an 8-year period (1984 to 1991) 66 patients (mean age 59 years, range 26 to 84 years) with type A aortic dissection (60 ascending aorta tears, 6 arch tears; 35 acute, 31 chronic) had surgical repair by a continuous suture-graft inclusion technique. Hypothermic circulatory arrest (16 degrees C) was used in 58 patients (35/35 acute, 23/31 chronic; mean arrest time 26 minutes, range 10 to 55 minutes). Fifty-two patients had hemiarch repair and 6 had total arch replacement. Aortic valve disease necessitated treatment in 38 patients (1 valved conduit, 20 valve replacements, 17 valve repairs). Recently 11 patients had valve repair by reconstruction of the native aortic root, by means of techniques similar to those used for homograft valve insertion. Operative mortality was 9% (14% acute, 3% chronic). Stroke occurred in 2 patients (3%) and was fatal in both. Variables suggestive of increased operative risk by univariate analysis were acuteness (p = 0.12), visceral ischemia (p = 0.12), and preoperative shock (p = 0.13). No variable was significant by multivariate analysis. Overall actuarial survival at 48 months was 77%, with 3 late deaths from a ruptured distal aneurysm. Late computed tomography or magnetic resonance imaging scan was done in 28 patients at a mean interval of 33 months. These studies identified 1 patient with a pseudoaneurysm requiring reoperation and 3 patients with contained flow between the graft and the wrap. Three patients required late operation: 1 for pseudoaneurysm, 1 for arch dissection, and 1 for repair of a distal aneurysm.     

Acute type A aortic dissection with leg ischemia

The incidence of lower extremity ischemia secondary to acute aortic dissection is relatively low, however, the presenting symptoms are variable in term of severity. We report here in two cases of such circumstances who were successively differently treated. Case one was a 60 years old male presented with severe left leg pain. Even after the initiation of cardiopulmonary bypass, the leg ischemia did not improve, therefore selective leg perfusion was additionally performed through direct left femoral artery cannulation. The surgery toward dissection was completed by mean of simultaneous graft replacement of ascending aorta and aortic arch. The leg ischemia after the aortic procedure however had persisted, femorofemoral bypass was created to relieve the mal-perfusion. Case two was a 37 years old male admitted with severe left leg pain associated with sensory-motor nerve dysfunction with muscle rigidity. In this particular patient, femoro-femoral bypass was firstly reconstructed as the mean of leg salvage procedure. After we learned there was no serious reperfusion symptom manifested, we performed radical surgery toward the aorta. We believe that the decision making of surgical treatment for acute type A dissection complicated with the presence of lower extremity ischemia is based on the severeness of mal-perfusion.     

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)     

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.     

Acute aortic dissection and ventricular septal defect repair

A 37-year-old male with long-standing heart murmur and ventricular septal defect developed acute chest pain and was diagnosed with an aortic dissection and aortic insufficiency. The ventricular septal defect and aortic dissection were repaired successfully as a combined procedure. At late follow-up (three years), he continued to enjoy an excellent result.     

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.     

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.     

Surgical treatment for acute aortic arch dissection

The authors describe 2 patients with Takayasu's arteritis in whom lupus anticoagulant was positive and the titer of anticardiolipin antibody was elevated. One patient developed diffusely stenotic and occlusive changes in the multiple larger arteries. Histology of the small-sized arteries in another patient showed occlusive vasculitis without thrombosis, in addition to the findings in large-sized arteries compatible with Takayasu's disease. These findings are uncommon in Takayasu's arteritis. These findings suggest that antiphospholipid antibodies may have contributed to the pathogenesis of the extensive vasculopathy and may have triggered vasculitis in these patients.     

Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk)

BACKGROUND: The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates. METHODS: Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures. RESULTS: The mean arrest time was 31.4 +/- 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line. CONCLUSIONS: The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.     

Two cases of annulo-aortic ectasia with type A aortic dissection reconstructed by reimplantation of the aortic valve

We performed aortic valve sparing operation in two cases of annulo-aortic ectasia combined with Type A aortic dissection. Marfan syndrome was found in one case and the dissection was acutely evolving in another case. The aortic valves were observed as normal configuration in both cases and then reimplanted within the synthetic grafts along with the David's procedure. No aortic regurgitation was found in the acute case but slight regurgitation was checked out in the Marfan case at the discharge. The aortic valve preserving operation for annulo-aortic ectasia was considered much effective in cases with aortic dissection in order to expect the thrombolization in the pseudo lumen.