ABSTRACT
A 75-year-old man was referred to our hospital with a chief complaint of sudden back pain and fever. Enhanced CT showed a Kommerell diverticulum (KD) with right aortic arch and aberrant left subclavian artery (ALSA). It also showed type B aortic dissection with a closed false lumen and the horizontal diameter of the KD was 73 mm. We decided on elective surgery because the size of the KD was so large ; he also had aortic dissection and difficulty in swallowing due to compression of the esophagus. We avoided thoracotomy because it was challenging to approach to the KD and reconstruct the ALSA in situ. There also was the risk of injury to organs around the KD especially the esophagus and trachea via thoracotomy. Therefore, we performed an elective one-stage operation comprising total arch replacement (TAR) and frozen elephant trunk (FET) through median sternotomy followed by thoracic endovascular aortic repair (TEVAR). We could perform the operation safely with a good field of view. This strategy did not need a thoracotomy or in situ reconstruction of the ALSA. The post-operative course was uneventful and he was discharged 18 days after the operation. A CT scan 6 months after the operation showed size reduction of the thrombosed KD with no residual leakage of the stent graft. This hybrid method is one effective option for a KD with right aortic arch and ALSA. We report a successful one-stage hybrid operation for KD with some literature review.
ABSTRACT
Objective : The mainstream strategy for blunt traumatic thoracic aortic injuries (BTAI) has been shifting from conventional open repair (OR) to thoracic endovascular aortic repair (TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods : We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results : Eighteen cases were identified. Of these, 7 patients (38.9%, mean age 62.0±15.2 years) were treated with OR and 11 (61.1%, mean age 61.8±21.3 years) were treated with TEVAR. There was significant reduction in the mean operative duration (OR 444±145 vs TEVAR 65±14 min ; p＜0.001), the mean intraoperative blood loss (OR 2,787±1,578 vs TEVAR 210±376 ml ; p＜0.001), the volume of blood transfusions (OR 5,042±2,219 vs TEVAR 929±751 ml ; p＜0.001), and the mean dose of heparin infusion (OR 20.3±4.1 vs TEVAR 7.9±8.5 ml ; p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0% (p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate (average follow-up period of 42.0±56.9 months). Conclusions : Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.
ABSTRACT
The patient in this case was a boy aged 2 years and 9 months. The patient was transferred to our hospital with ductal shock, and bilateral pulmonary artery banding was performed on the 9th day after the diagnosis of interruption of the aortic arch, ventricular septal defect, subaortic stenosis, and bicuspid aortic valve. Left ventricular outflow tract stenosis due to aortic annulus diameter and subaortic stenosis after repair was suspected. Damus-Kaye-Stansel (DKS) anastomosis, extended aortic arch anastomosis, and a right modified Blalock-Taussig operation were performed. Preoperative examination of the intracardiac repair showed growth of the aortic annulus and confirmed that biventricular repair was possible after DKS take-down. The patient's native aortic and pulmonary valves were preserved, and an intracardiac repair was performed without using an extracardiac conduit. The postoperative course was uneventful, and the patient is currently in a good condition at the age of 6 years. Three and a half years after surgical intervention, echocardiography and cardiac catheterization showed improvement of subaortic stenosis and enlargement of the aortic annulus. Our findings indicate that the most appropriate surgical procedure can be selected by detailed examination of the preoperative condition at each stage of the staged operation.