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.     

Experience of reoperations followed by repairs of abdominal aortic aneurysms

We experienced 8 cases who required reoperations, including 2 re-redo operations, after repairs of infrarenal abdominal aortic aneurysms. Of 8 patients, one patient developed a new aneurysm due to atherosclerosis in thoraco-abdominal aorta involving all visceral arteries and other 7 patients had aneurysmal formations at proximal anastomotic sites, including 3 suprarenal, 2 juxtarenal and 2 infrarenal aortic lesions. Etiology at initial operation in patients who subsequently developed anastomotic aneurysms included vasculo-Beh?et disease in 4, atherosclerosis in 2 and dissecting aortic aneurysms type III due to Marfan syndrome in 1. At reoperation, all who had vasculo-Beh?et disease had ruptures of anastomotic sites and 2 patients underwent repairs of dehiscent patch, 1 extra-anatomic bypass between ascending and abdominal aorta and 1 interposition of graft. One patient who had graft infection after repair of abdominal aortic aneurysm required axillo-femoral bypass with removal of infected graft. A patient who had dehiscence of proximal anastomosis after repair of aortoiliac occlusive disease required interposition of graft. Two patients, Marfan syndrome and aneurysm in thoraco-abdominal aorta, underwent graft replacement of thoraco-abdominal aorta concomitant with reconstruction of all visceral arteries. There were 8 patients who required reoperations for aneurysms at distal anastomotic sites after repairs of abdominal aortic aneurysms. Five patients underwent repairs of new aneurysms, including replacement of total arch in 3, descending aorta in 1 and iliac artery in 1. In all cases, no hospital death was noted, however, late deaths were occurred in vasculo-Beh?et disease, Marfan syndrome and graft infection. Thus, late result depends on etiology of disease. Although patients who requires reoperation after repair of abdominal aortic aneurysms have higher operative risk factors, early and late results are satisfactory compared to initial operations.     

Redo operation after surgery for aortic aneurysm and dissection

Thirteen patients who underwent redo operation after surgical treatment of aortic aneurysm and dissection were presented. In 8 patients, redo operations were performed for aortic dissection following aortic valve replacement. A-C bypass, the Koster-Collins operation and replacement of thoracic aorta. In the other 5 patients, the reasons for redo operation were aortic root enlargement after replacement of ascending aorta and aortic valve replacement, pseudoaneurysm and aneurysmal dilatation around coronary button for the Bentall operation and recurrent aneurysm after patch aortoplasty and thoracoabdominal replacement using the Crawford's maneuver. To prevent these redo operation, adequate selection of surgical procedures and meticulous operative techniques should be required in primary operation.     

Surgical implication of aortic dissection on long-term outcome in Marfan patients

We herein review our 17-year surgical experience for the treatment of ascending aortic aneurysm in patients with Marfan syndrome to clarify the risks of increased mortality and reoperation. The subjects consisted of 15 patients who had all undergone surgery for the aortic root and ascending aorta at Niigata University Hospital between July 1978 and January 1995. Aortic valve replacement and ascending aortic wrapping were performed in 5 patients, Bentall or Cabrol operation in 6, and combined aortic arch reconstruction and Cabrol operation in 2, as the initial surgery. Patients who had an aortic dissection (Stanford type A) at initial surgery were assigned to group I (n = 7), while those with an aortic root aneurysm were assigned to group II (n = 8). In group I, 3 patients required a second operation for the remaining aortic arch aneurysm, and 1 died due to a late rupture of the distal aneurysm. In group II, no patient needed a reoperation; however, 1 died due to an intracranial hemorrhage and another due to composite valve graft failure and distal dissection. The results thus indicate that aortic dissection seems to affect long-term outcome, and therefore the combined repair of the aortic root and transverse arch is recommended in Marfan patients with aortic dissection involving the transverse aortic arch.     

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.     

Beyond self-interest. Professional advocacy and the integration of theory, research, and practice

Autosomal dominant inheritance of thoracic aortic aneurysms and dissections occurs in subjects with Marfan syndrome, which results from mutations in the FBN1 gene on chromosome 15. A second chromosomal locus on 3p24-25 has been identified for a Marfan-like condition with thoracic aortic aneurysms. We describe here 6 families with multiple members with thoracic aortic aneurysms and dissections in the absence of the ocular and skeletal complications of Marfan syndrome. Medical records and autopsy reports on affected subjects in families with multiple members with thoracic aortic aneurysms and dissections were reviewed. Subjects in these families at risk for developing aortic disease underwent echocardiography to evaluate the aorta. The pattern of inheritance of thoracic aortic aneurysms and dissections was autosomal dominant in these families. Most affected subjects presented with aortic root dilatation or acute type I dissection, but the age of onset of disease was variable and there was decreased penetrance of the disorder. In 2 of the families, the syndrome was not linked to FBN1 or 3p24-25. Familial thoracic aortic aneurysm and dissection is an autosomal dominant condition with marked variability in the age of onset of aortic disease and decreased penetrance, making identification of affected subjects difficult. This condition is not due to mutations in the FBN1 gene or the unidentified gene on 3p24-25.     

Tuberculosis: infection control measures

A 58-year-old man with acute mitral and aortic endocarditis suffered an acute ascending aortic dissection. The patient had a double valve replacement, combined with replacement of the ascending aorta with a Dacron graft and sealing and closure of the proximal and distal aortic segments with surgical glue. Six months after the operation the patient is doing well with normal function of both valve prostheses and aortic vascular graft.     

Endovascular stent graft repair for aneurysms on the descending thoracic aorta

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.     

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.     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

Non clamping anastomosis of the ascending and arch aneurysm using retrograde cerebral perfusion

Twelve consecutive patients requiring surgery for replacement of ascending aortic aneurysms (n = 3), ascending arch aortic aneurysms (n = 2), or type A aortic dissections (n = 7) were treated without aortic cross clamping. Retrograde cerebral perfusion (RCP) with circulatory arrest (mean RCP time: 46.0 +/- 15.9 minutes, range 20 to 65 minutes) and continuous retrograde cardioplegia (mean cardiac ischemic time: 134.4 +/- 39.7 minutes, range: 40 to 180 minutes) were employed. In the patients with aortic dissection, the intimal tear at the origin of the brachiocephalic artery (BCA) was resected completely, the aortic wall was trimmed and closed with Teflon felt. The distal anastomosis was created using an open technique. Air and debris were completely evacuated by returning blood from the cerebral vessels and femoral artery. Then the artificial graft was clamped, and cardiopulmonary bypass resumed. The proximal anastomosis was performed during rewarming. The operations were elective in seven cases, and emergent in five cases. Graft replacement of the ascending aorta was performed in ten patients (including two BCA reconstructions). The remaining two patients were treated by patch repair (n = 1), primary anastomosis (n = 1). There were no perioperative deaths. One patient had a transient neurological deficit. The distal false lumen was occluded completely in five of seven patients with aortic dissections. The other two patients had a secondary tears in the descending aorta. Thus retrograde cerebral perfusion and continuous retrograde cardioplegia without aortic cross clamping is an effective technique in the replacement of the ascending and arch aorta.     

Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root

OBJECTIVES: There is still no agreement about the best method of dealing with malfunction of the aortic valve caused by aneurysm or dissection of the aortic root. The experience, rationale, and development of a valve-preserving technique introduced and used since 1979 is described. METHODS: During this period 158 patients (78% of all patients undergoing resection of aneurysm of the ascending aorta) were operated on using this technique. Their ages ranged from 2 to 72 years (mean 46.6 years). Of the patients 107 were male and 51 were female. A total of 68 patients had skeletal manifestations of Marfan's syndrome. The original disease was chronic aneurysm of the ascending aorta or root in 92 (58.2%), chronic dissection in 17 (10.8%), and acute dissection in 49 (31%) patients. One hundred eleven additional procedures were performed in 84 patients. In all there were five early deaths (4.6% +/- 2%) in the 109 patients with chronic aneurysm and one death in the 103 patients operated on electively (0.97% +/- 0.9%). Actuarial survival for patients operated on for chronic aneurysm was 93.3%, 88.0%, 79.0%, and 57.9% at 1, 5, 10, and 15 years and 96.8%, 91.2%, 82.0%, and 60.0% for those operated on electively. Actuarial survival for patients operated on for acute dissection was 72.8%, 63.4%, and 53.3% at 1, 5, and 10 years. The probability of needing reoperation was 3.0% +/- 2%, 11% +/- 0.5%, and 11% +/- 0.5% at 1, 5, and 10 years. There were no instances of infective endocarditis or thromboembolic complications except in two patients operated on early in the series who had cusp extension. No anticoagulants were used. Echocardiography showed reduction in left ventricular end-systolic and end-diastolic dimensions, which was maintained. At the end of follow-up trivial or no aortic regurgitation was demonstrated in 63.6%, mild to moderate in 33.3%, and severe in 3%. CONCLUSIONS: Valve-sparing operations are possible in a large proportion of patients with aneurysms of the ascending aorta and the medium and long-term results are encouraging.     

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.     

Bilateral subclavian artery aneurysm associated with idiopathic cystic medial necrosis

Although cystic medial necrosis, either idiopathic or associated with Marfan's syndrome, usually becomes manifest as an ascending aortic aneurysm, aortic insufficiency, aortic dissection, or a combination of these disorders, a rare case of bilateral subclavian artery aneurysm secondary to idiopathic cystic medial necrosis has occurred. Subclavian artery aneurysms most commonly represent poststenotic dilatation from anterior scalene or cervical rib compression, occasionally are associated with generalized arteriosclerotic peripheral vascular disease, and rarely are secondary to syphilitic or mycotic infections. Subclavian artery aneurysms have a major risk of rupture, embolus, or thrombosis, and therefore should be repaired. A reverse saphenous vein or prosthetic bypass graft from the carotid to the axillary artery provides adequate flow to the upper extremity. The aneurysm should be completely excised if possible, since reexpansion through small collaterals or through insufficient closure by ligation can occur and compress the brachial plexus after successful bypass. The clinical presentation, angiographic findings, and operative repair of a subclavian artery aneurysm secondary to cystic medial necrosis are described.     

Unique retina cell phenotypes revealed by immunological analysis of recoverin expression in rat retina cells

OBJECTIVE: This study was undertaken to determine the impact of previous cardiac surgery on the presentation, management, and outcome of late dissection of the ascending aorta. PATIENTS AND METHODS: From 1976 to 1998, type A dissection developed in 56 patients with a history of previous cardiac surgery. Interval from first operation to type A dissection was 49 +/- 47 months (0.3-180 months). Previous operations were coronary artery bypass grafting (n = 40), aortic valve replacement (n = 8), and other (n = 8). RESULTS: Type A dissection was acute in 34 patients and chronic in 22. In acute dissection, aortic insufficiency occurred in 50%, malperfusion in 12%, and rupture in 18%; 2 patients (6%) were in hemodynamically unstable condition because of rupture. Of patients with previous coronary bypass grafting, 98% had preoperative coronary angiography. Type A dissection was treated by supracoronary tube graft (84%), Bentall procedure (14%), or local repair (2%). Strategies for managing previous coronary bypass grafting included reimplantation of proximal anastomoses with a button of native aorta (29 patients), interposition graft to pre-existing saphenous vein grafts (9 patients), and new saphenous vein grafts (20 patients). Eight hospital deaths occurred (14%). CONCLUSIONS: We conclude that (1) patients having type A dissection late after cardiac surgery infrequently have cardiac tamponade and hemodynamic collapse; (2) patients with previous coronary bypass grafting require coronary angiography, because operative management must account for pre-existing coronary artery disease; and (3) operative mortality is low, and this may be attributable to preoperative hemodynamic stability, delineation of coronary anatomy in those with previous coronary bypass grafting, and operative treatment of coronary artery disease.     

Differential expression of heat shock proteins in normal and failing human hearts

OBJECTIVE: To predict spinal cord ischemia after endovascular stent graft repair of descending thoracic aortic aneurysms, temporary interruption of the intercostal arteries (including the aneurysm) was performed by placement of a novel retrievable stent graft (Retriever) in the aorta under evoked spinal cord potential monitoring. METHODS: From February 1995 to October 1997, endovascular stent graft repair of descending thoracic aortic aneurysms was performed in 49 patients after informed consent was obtained. In 16 patients with aneurysms located in the middle and distal segment of the descending aorta, the Retriever was placed temporarily before stent graft deployment. The Retriever consisted of two units of self-expanding zigzag stents connected in tandem with stainless steel struts. Each strut was collected in a bundle fixed to a pushing rod, and the stent framework was lined with an expanded polytetrafluoroethylene sheet. The Retriever was delivered beyond the aneurysm through a sheath and was retracted into the sheath 20 minutes later. A stent graft for permanent use was deployed in patients whose predeployment test results with the Retriever were favorable. Evoked spinal cord potential was monitored throughout placement of the Retriever and stent grafting until the next day. RESULTS: The Retriever was placed in 17 aneurysms in 16 patients. There were no changes in amplitude or latency of evoked spinal cord potential records obtained before or during Retriever placement. After withdrawal of the Retriever, all aneurysms were excluded from circulation immediately after permanent stent grafting. There were no changes in evoked spinal cord potential, nor were neurologic deficits seen after stent graft deployment in any patient. CONCLUSIONS: These results suggest that predeployment testing with the Retriever under evoked spinal cord potential monitoring is promising as a predictor of spinal cord ischemia in candidates for stent graft repair of thoracic aortic aneurysms.     

Modified David''s operation for aortic regurgitation associated with annulo-aortic ectasia

Composite graft replacement of the ascending aorta and aortic valve has been indicated for aortic regurgitation (AR) associated with annulo aortic ectasia (AAE). 29-year-old female with AR due to AAE associated with Marfan's syndrome underwent the replacement of ascending aorta by sparing an aortic valve with good result. Under cardiopulmonary bypass, the proximal ascending aorta was dissected circumferentially down to the ventriculo-aortic junction. The aneurysmal aorta and the all three sinuses of valsalva were excised, leaving 7 mm of arterial wall attached to the aortic valve and small buttons of arterial wall around the both left and right coronary arteries. The aortic valve was reimplanted inside a 28 mm Dacron graft which was calculated by aortic valve leaflet height. The left coronary artery was reimplanted to the graft by interposing a short 10 mm Dacron graft between coronary ostia and graft and the right coronary artery was anastomosed directly to the graft (Piehler's procedure). We called these procedure "modified David's operation". The patient has survived the operative procedure without any complications. Postoperative aortogram showed a competent aortic valve and the peak systolic pressure gradient across the aortic valve was 20 mmHg. We believe this new procedure preserving the native aortic valve is useful for preventing from some complications associated with artificial heart valves.     

Identification and characterization of kraken, a gene encoding a putative hydrolytic enzyme in Drosophila melanogaster

BACKGROUND AND AIMS OF THE STUDY: The study aimed to determine the clinical performance of bovine pericardial aldehyde-treated products alone or in combination with aortic leaflets of porcine origin. These included a composite porcine stentless aortic valve attached to a scalloped pericardial tube (BSAV), and valved and non-valved bovine pericardial conduits for use in left-sided heart lesions (BPG). METHODS: For BSAV grafts, between January 1990 and August 1996, 163 patients (119 males) had their aortic valves replaced by SJM Biocor BASV. Mean age was 37.9 +/- 17.6 years (range: 1 to 76 years). Rheumatic heart disease sequelae (n = 72) and replacement of a prosthetic heart valve (n = 46) were predominant. Preoperative NYHA functional class showed 90 patients (55.2%) in class III and 50 (30.7%) in class IV. BPVC and NVPC grafts were used in 166 patients: acute aortic dissection was the main indication in 52 (31.3%) and chronic in 36 (21/7%). The ascending aorta was involved in 141 patients (84.9%); grafts were seldom used at other sites. In most patients the graft implanted was either a non-valved (n = 79) or a valved (n = 75) pericardial conduit. Twelve patients had a localized lesion and required a patch repair. RESULTS: For BASV grafts, the non-valve-related hospital mortality rate was 4.9%. There were 14.7% non-fatal complications with full recovery of all patients. Mean follow up in 141 patients was 3.0 +/- 1.4 years (range: 1 month to 7.2 years); 14 patients were lost to follow up. Late, non-conduit-related, mortality occurred in seven patients (4.9%). Eight patients underwent reoperation. The current clinical follow up of 127 patients has shown 118 (92.9%) with competent valves and nine (7.0%) with mild stable aortic insufficiency. For BPVC and NVPC grafts, hospital mortality rate was 16.9%, death being related to poor preoperative clinical condition. Postoperative follow up was accomplished in 125 patients; reoperation was necessary in seven patients. Histology showed good tissue preservation up to five years; echocardiography revealed satisfactory findings. No valved conduit had to be reoperated for valve or pericardial tissue wear. CONCLUSIONS: Clinical results of left-sided heterologous pericardial grafts have shown excellent performance over time. The BASV (over seven years) and BPVC and NVPC (eight years) have demonstrated superior results as aortic valves alone or in combination with a pericardial conduit.     

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 pseudoaneurysm after repair of thoraco-abdominal aortic aneurysm

We report a 63-year-old female patient developing a pseudoaneurysm three years after patch-plasty of an aneurysm located at the distal thoracic aorta. Redo-operation was performed including total replacement of the descending thoracic aorta with reimplantation of distal intercostal arteries using small-caliber interposition grafts. This case presentation underlines the ineffectiveness of patch repair for the treatment of aortic aneurysms. Furthermore, the surgical technique of reimplantation of intercostal arteries using a separate graft is discussed.