Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration

PURPOSE: The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection. METHODS: Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections. RESULTS: Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma. CONCLUSION: EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.     

Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta

BACKGROUND: Aortic dissection with branch obstruction is associated with high morbidity and mortality. Fenestration of the dissection flap to relieve distal vessel ischemia is at present largely performed surgically. The surgical mortality and morbidity are high, because most patients are poor candidates for anesthesia or surgery. METHODS AND RESULTS: Nine percutaneous fenestrations (one with additional stenting of the infrarenal true aortic lumen) were performed under local anesthesia in seven patients with aortic dissection. The presenting symptoms were abdominal angina or claudication. By the transfemoral approach, the intimal flap was initially punctured with a needle-catheter combination through which a guidewire was placed across the dissection flap. The fenestration was carried out with a balloon catheter introduced over the guidewire. The procedure was performed under on-line guidance with intravascular ultrasound imaging. The procedure was performed successfully and without complications in all patients. After intervention, symptoms resolved in all seven patients. CONCLUSIONS: Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in symptomatic aortic dissections with distal vessel involvement is a technically feasible and safe procedure that can effectively relieve the patient's symptoms.     

Percutaneous creation of acute type-B aortic dissection: an experimental model for endoluminal therapy

PURPOSE: To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap. MATERIALS AND METHODS: Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach. The initial subintimal tear was made with use of a Colapinto needle. The dissections were extended to a predefined position in the aorta. The proximal and distal tears were balloon dilated. The mural flap was balloon fenestrated in six animals, just above the celiac artery. Aortograms were obtained to establish the presence and extent of the dissection. Manometry was performed in both lumina to evaluate the hemodynamics of the dissected aorta and the effects of balloon fenestration in this model. Pathologic specimens were also examined. RESULTS: Creation of dissection was successful in 11 of 15 animals, with six developing true lumen narrowing (group A). The other five animals (group B) had flow in both lumina without evidence of true lumen narrowing. After the creation of a single-balloon fenestration in the group A swine, the arteriograms revealed no evidence of blood admixture between the true and false lumina, and there was no change in the intravascular pressures. Examination of the explanted aortae showed a more extensive circumferential dissection in group A animals as compared with group B. CONCLUSION: The percutaneously created acute type-B aortic dissection is a feasible model for experimentation. The hemodynamics of the aorta did not change after single-balloon fenestration in this model.     

Amebic encephalitis caused by Balamuthia mandrillaris in a Czech child: description of the first case from Europe

Lower leg ischemia associated with aortic dissection is a potentially life-threatening condition requiring immediate treatment. To better understand the diagnostic factors and improve the treatment strategy of this serious complication, we analyzed our experience regarding the radiographic findings, treatment, and outcome in eight patients (aged 28-72 years, six men and two women). CT revealed type A aortic dissection in seven patients and type B in one. The obstructed site was in the iliac artery in five patients and in the abdominal aorta below the renal arteries in three. Surgical procedures included five ascending aortic graft replacements, three femoro-femoral bypasses, and one each of surgical fenestration, aorto-iliac bypass, and axillo-femoral bypass with thrombectomy. Endovascular treatment was performed in two patients, iliac stent placement in one, and thrombolysis of the iliac artery in one. Five patients survived and three died due to myonephrotic metabolic syndrome in two and postoperative bleeding in one. Treatment strategy depends on several issues regarding aortic dissection including ascending aortic involvement, patent false lumen, entry site, renal artery involvement, and thrombosis in a true or false lumen. CT and angiography are the most important methods for deciding upon appropriate therapy in each individual.     

Sexual orientation and family development: introduction

A new guiding catheter for PTCA is described. In our department, 302 patients (405 lesions) underwent transradial coronary angioplasty using the 6 Fr Kimny guiding catheter since January 1996. The total engagement rate using the Kimny guiding catheter was 91.3% (370/405). The engagement rate after the modified Kimny guiding catheter was introduced in May 1996 increased to 96.0% (243/253). The stent delivery success rate was 98.4%. We had two dislodged stents. PTCA for both left and right coronary arteries in a single procedure with the Kimny guiding catheter was performed via the radial artery in 27 patients. In 24 of these patients (89%) we engaged both coronaries successfully. In the remaining 3 patients we switched to another catheter. Except for 4 patients with non-Q-wave myocardial infarction, no major cardiac complications were encountered. No major entry site-related complications were seen, and no patient required vascular surgery or blood transfusions. In one patient the Kimny guiding catheter tip caused a minor dissection of the LMT, but no ischemic event occurred as a result. In conclusion, the Kimny device is a useful PTCA guiding catheter for routine angioplasty and stenting.     

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.     

Evaluation of HBsAg carrier rate in acute viral hepatitis and high risk individuals using RPHA and ELISA

INTRODUCTION: Balloon valvuloplasty in neonates and small infants with critical aortic stenosis is a palliative procedure. The present report describes the results of the technique in our center. METHODS: From April 1993 to March 1995, six consecutive patients with critical aortic valve stenosis underwent catheter-balloon valvuloplasty. Their ages ranged from 2 to 120 days old (45.5 +/- 47.5 days). Four patients had associated lesions: 2 had coarctation of the aorta, 1 had ischemic dilated cardiomyopathy and 1 had endocardial fibroelastosis. Percutaneous femoral artery access was used in four cases and axillary artery dissection in two. RESULTS: The balloon-annulus diameter ratio was 0.92 +/- 0.12. The peak systolic ejection gradient decreased from 66.1 +/- 26.4 to 38 +/- 15.7 mmHg (p < 0.05) and the left ventricle systolic pressure decreased from 136.3 +/- 26.8 to 115 +/- 22.5 mmHg (p < 0.05). There were no mortalities related to the procedure. Both patients who had aortic coarctation developed aortic regurgitation and died after repairing of the coarctation. The patient with endocardial fibroelastosis died during an attempt to perform the Norwood operation (Stage I) and the other patient with ischemic dilated cardiomyopathy survived after cardiac transplantation. The remaining two patients with isolated aortic valve stenosis are currently asymptomatic. CONCLUSIONS: Catheter-balloon valvuloplasty is an effective procedure in the initial treatment of critical aortic stenosis and may be life saving.     

Reversal of proinflammatory responses by ligating the macrophage Fcgamma receptor type I

OBJECTIVE: The purpose of the study was to evaluate the use of renal artery stents in the solitary functioning kidney of patients who have impaired renal function as a result of atherosclerotic renovascular disease by assessing primary patency, renal function outcome, and complication rates during a mean follow-up period of 15 months. MATERIALS AND METHODS: The Palmaz stent was placed in the arteries of 21 patients with solitary functioning kidneys. All patients had impaired renal function (creatinine level >150 micromol/l), and four patients were undergoing renal dialysis. Indications for stenting were recoil after percutaneous transluminal angioplasty (n = 12), arterial dissection after angioplasty (n = 2), restenosis after angioplasty (n = 1), and as the primary intervention (n = 6). Follow-up angiography was performed in 16 patients (76%). RESULTS: Initial technical success was achieved in all patients (residual stenosis, <5%). At follow-up (range, 6-25 months), renal function had returned to normal in five patients (24%), improved in four patients (19%), stabilized in six patients (29%), and deteriorated in six patients (29%). Dialysis has been discontinued in all four dialysis patients. Major complications occurred in four patients (19%), including one death within 30 days of stenting. No significant restenoses were seen on follow-up angiography. CONCLUSION: Placement of renal artery stents in the solitary kidney led to benefits in 70% of patients treated, including improved renal function in nine patients (43%) and stabilization in six patients (29%). In this high-risk group of patients, we advocate renal artery stenting as a relatively safe procedure to salvage the solitary kidney.     

Outcome of percutaneous intervention in iliac artery stents

PURPOSE: To assess the safety and efficacy of secondary procedures in iliac artery stents. MATERIALS AND METHODS: Thirty-four patients (36 limbs) underwent one or more interventional procedures in iliac artery stents to treat restenosis (n = 30) or occlusion (n = 6). All patients were followed up by means of clinical and angiographic examination. Primary and secondary patency were assessed with angiography, duplex ultrasound, or both. Primary patency was determined after one interventional procedure, and secondary patency was determined at the end of the study (mean +/- standard deviation, 20.1 months +/- 17.5; range, 1-58 months). RESULTS: Immediate angiographic success was achieved in all cases. Four complications were observed. The primary and secondary cumulative patency rates were 77.5% +/- 7.6 and 94% +/- 4.1 at 6 months, 73% +/- 8.4 and 89.3% +/- 6 at 12 months, and 51.4% +/- 10.9 and 78.8% +/- 8.8 at 2 years. At the end of the study, 80% of the arteries were still nominally patent. CONCLUSION: Restenosis and chronic occlusion in iliac artery stents can be treated with percutaneous interventional procedures; however, stenosis can still recur.     

Stent recoil: comparison of the Wiktor-GX coil and the Palmaz-Schatz tubular coronary stent

Wiktor-GX coil stents and Palmaz-Schatz 154A tubular stents were implanted in a consecutive series of 40 patients and 45 arteries undergoing successful primary stent placement in de novo lesions treated with single stents in order to compare the acute recoil of a coil stent to a tubular stent in native coronary arteries. Acute stent recoil was determined by measuring the difference between the maximum inflated diameter of the stent deployment balloon and the minimum lumen diameter after stent deployment. There was no difference between the two groups for reference vessel diameter, nominal balloon diameter, maximum inflated balloon diameter, maximum inflation pressure, or poststent vessel minimum lumen diameter. Acute recoil averaged 0.15 +/- 0.2 mm for the Wiktor-GX and 0.13 +/- 0.1 for the Palmaz-Schatz (P = 0.58). In this series of patients, there was no significant difference between the acute recoil of the coil stent compared to the tubular stent.     

Systemic hypertension as a risk factor for complications with an aortic mechanical valve

We sought to determine the effect of preoperative systemic hypertension on prosthesis related complications or postoperative aortic dissection after valve replacement in patients with aortic regurgitation. The patients were divided into two groups according to the presence or absence of systemic hypertension: Group I, with hypertension (n = 35), and Group II, without hypertension (n = 37). The survival rate and event free rate were examined for 72 patients who were alive 30 days after valve replacement with a St. Jude Medical valve for aortic regurgitation. The cumulative 10 year survival rate of Group I (65% +/- 12%) was lower than that of Group II (79% +/- 15%). The 10 year event free rate of all prosthesis related complications was 62% +/- 13% in Group I, and 96% +/- 3% in Group II (p < 0.05). The 10 year event free rate for ascending aortic dissection was 73% +/- 12% in Group I and 100% in Group II (p < 0.05). The linearized event rate of all prosthesis related complication was 3.8% per patient-year in Group I and 0.5% per patient-year in Group II. In conclusion, systemic hypertension was a risk factor for prosthesis related complications and for complicated aortic lesions after aortic valve replacement. Careful postoperative management for hypertension is necessary in patients with systemic hypertension after aortic valve replacement. Tissue valves may be recommended in patients with aortic valve disease and severe hypertension.     

Open distal anastomosis in retrograde cerebral perfusion for repair of ascending aortic dissection

BACKGROUND: In patients with aortic dissection, a patent distal false lumen at long-term follow-up leads to complications. We investigated the feasibility of performing an open distal anastomosis using retrograde cerebral perfusion. METHODS: Over a 10-year period, 41 patients with acute type A aortic dissection underwent 43 surgical repairs. In 1991, an open distal anastomosis using retrograde cerebral perfusion (group 2) was introduced to replace the standard aortic cross-clamp method (group 1). The mean retrograde cerebral perfusion time was 47.3 minutes (range, 22 to 67 minutes), and there were no neurologic sequelae in surviving patients. RESULTS: The operative mortality rate was 18.5% in group 1 and 18.7% in group 2. At long-term follow-up, dilatation of the false lumen (more than 50 mm in diameter) occurred in 9 of 18 patients (50%) in group 1, and 2 patients died of aortic rupture. There were no deaths in group 2, and dilatation of the distal false lumen occurred in only 15.4% of patients (p < 0.05). CONCLUSIONS: The use of retrograde cerebral perfusion in patients with acute aortic dissection provides adequate time to perform a safe, open, distal anastomosis, and could decrease significantly the rate of enlarged, patent, false lumina.     

Does stent placement improve the results of ineffective or complicated iliac artery angioplasty?

OBJECTIVE: This study was undertaken to determine the results and complications of stents placed for initially unsuccessful or complicated iliac percutaneous transluminal angioplasty (PTA), the effect of location (external iliac or common iliac) on outcome, and the influence of superficial femoral artery patency on benefit. DESIGN: From 1992 through 1997, 350 patients underwent iliac artery PTA at the authors' institutions. Of this group, 88 patients (88 arteries) had one or more stents placed after PTA (140 stents in total) for residual stenosis or pressure gradient (63 patients), iliac dissection (12 patients), long-segment occlusion (10 patients), or recurrent stenosis (3 patients). Thirty patients required the placement of more than one stent. The indications for PTA in these 88 patients were claudication (48 patients) and limb-threatening ischemia (40 patients). Forty-seven patients had stents placed in the common iliac, 29 patients had stents placed in the external iliac, and 12 patients had stents placed in both. Seventy-one arteries (81%) were stenotic, and 17 (19%) were occluded before PTA. Sixty-six arteries were treated by interventional radiologists, 15 by a vascular surgeon, and 7 jointly. MAIN OUTCOME MEASURE: Criteria for success included (1) increase of at least one clinical category of chronic limb ischemia from baseline or satisfactory wound healing, (2) maintenance of an ankle/brachial index increase of more than 0.10 above the preprocedure index, and (3) residual angiographic stenosis less than 25% and, for patients with pressure gradient measurements, a residual gradient less than 10 mm Hg. RESULTS: Stent placement was accomplished in all 88 patients with 16 (18%) major complications. Mean follow-up was 17 months (range, 3 to 48 months). By life-table analysis, success was 75% at 1 year, 62% at 2 years, and 57% at 3 years. No cardiovascular risk factor or independent variable was statistically significant in predicting success. There was no difference in success rates for common iliac or external iliac lesions. Superficial femoral artery patency did not correlate with outcome. CONCLUSIONS: Although stents can eliminate residual lesions and arterial dissection, these patients are likely to require adjuvant or subsequent procedures to attain clinical success. By controlling the PTA complication and treating the emergent problem, stents may allow for subsequent elective intervention.     

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.     

Angioplasty of atheromatous hemodynamic stenoses of intracranial vertebral arteries

We describe three patients presenting transient ischemic attacks or minor stroke, relapsing despite anticoagulation and antiplatelet therapy, in relation to tight stenosis of the intracranial vertebral arteries, without functional communicating arteries. Percutaneous transluminal angioplasty was successfully performed. We have a 6, 24 and 36 months follow-up. After a review of the literature, we discuss indication and risks of this procedure.     

Redo aortic grafting after treatment of aortic graft infection

PURPOSE: This study was performed to determine the indications, operative strategy, and hemodynamic benefit of redo aortic grafting procedures after earlier excision of an infected aortic graft. METHODS: Among 164 patients treated for aortic graft infection, 15 later underwent redo aortic grafting procedures an average of 18 months (range, 1 to 59 months) after removal of an infected aortic graft. Redo grafting procedures were performed for leg ischemia (n = 11) or infection (proven, n = 3; suspected, n = 1). The new aortic graft originated either from the distal thoracic aorta (n = 5) or from the juxtarenal aortic stump (n = 10). Follow-up averaged 56 months (range, 7 to 110 months). RESULTS: All patients survived the redo grafting procedure. In the eleven patients who had ischemic symptoms, redo grafting procedures uniformly resulted in symptomatic improvement with an increase in ankle-brachial indexes (0.78 +/- 0.34 vs 0.50 +/- 0.29; p = 0.02). A graft limb occlusion developed in two of these patients (3 and 6 months), but no limbs were amputated. In the four patients who had proven or suspected extraanatomic bypass graft infection, there was one graft limb occlusion (29 months) and one amputation (17 months). Overall, recurrent graft infection occurred in three of 15 patients and may be more frequent in patients who have a proven extraanatomic bypass graft infection (2 of 3 vs 1 of 12; p = 0.08). Infection accounted for two of the three graft limb occlusions and two of the three late deaths. Recurrent infection was not associated with early (< 1 year) regrafting procedures, and culture results did not correlate with the microbiologic features of the primary infection. CONCLUSIONS: Redo aortic grafting procedures can be performed safely and at relatively early intervals (6 to 12 months) after removal of the infected aortic graft. The procedure reliably relieves ischemic symptoms of the hemodynamically inadequate extraanatomic bypass graft. Reinfection remains a risk after redo aortic grafting procedures, particularly when treating established extraanatomic bypass graft infection.     

Primary stenting of de novo lesions in small coronary arteries: a prospective, pilot study

Technical advancement and new anti-thrombotic regimens have recently shown so much improvement in the results of coronary stenting that the conventional contra-indication for stenting in small coronary arteries (<3 mm) needs to be revised. We undertook a prospective pilot study of elective Palmaz-Schatz stenting in de novo lesions located in coronary arteries of less than 3 mm diameter. Fifty consecutive patients (63 +/- 9 years) with stable (n = 38) and unstable angina (n = 12) were included. Philips-DCI quantitative coronary analysis was used to measure reference diameter, minimal lumen diameter and percent diameter stenosis before PTCA, after stenting and at 6-month angiographic follow-up study. All measurements were performed after intracoronary injection of nitroglycerin (300 microg). All patients received ticlopidine (250 mg/day) and aspirin (100 mg/day). The mean lesion length was 9 +/- 3 mm. The balloon size used for stent delivery was 2.75 mm in 30 patients and 2.5 mm in 20 patients and the mean balloon inflation pressure used for stent deployment was 12 +/- 2 atm. All stents were deployed successfully. In-hospital complications occurred in two patients, diagonal branch occlusion at day 2 requiring emergency PTCA in one and a hematoma at the femoral puncture site requiring surgery in the other. Major adverse cardiac event (MACE) rate remained 2% (nonfatal infarct in one). Follow-up angiography (n = 46, 92%) at 6 +/- 3 months showed a 30% restenosis rate. Target vessel revascularization (TVR) rate was 13%. We conclude that elective stenting in small coronary arteries is feasible and involves an acceptable risk of restenosis.     

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.     

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.