A Case of Total Arch Replacement Using Coil Embolization for a Thoracic Aortic Aneurysm Derived from a Kommerell Diverticulum / 日本心臓血管外科学会雑誌

An 81-year-old man who visited a local physician for evaluation of hoarseness was admitted to our hospital for management of a thoracic aortic aneurysm. Careful examination revealed a thoracic aortic aneurysm, aortic regurgitation, and left ventricular aneurysm. We performed total arch replacement using a frozen elephant trunk prosthesis (combined right axillary artery bypass and coil embolization), aortic valve replacement, papillary muscle approximation, and a septal anterior ventricular exclusion operation. The patient's postoperative course was uneventful, and he was discharged on the 25th postoperative day. A Kommerell diverticulum is located at the origin of an aberrant subclavian artery, and subclavian artery reconstruction via thoracotomy is challenging in such cases. Although increasing numbers of thoracic endovascular aortic repairs have been performed in recent years, the procedure is associated with complications such as endoleak and aortic esophageal fistula, and the surgical risk-benefit ratio should be carefully determined. We report a case of safe non-anatomical subclavian artery reconstruction and coil embolization.

Successful Use of a Stent-Graft for Treating a Pseudoaneurysm Located at the Anastomosis of the Ascending Aorta and the Great Saphenous Vein / 日本心臓血管外科学会雑誌

Takayasu Arteritis causes annuloaortic ectasia and coronary ostial stenosis, which may necessitate open heart surgery. However, pseudoaneurysms are sometimes observed postoperatively, making subsequent treatment difficult. We report thoracic endovascular aortic repair of a pseudoaneurysm of the ascending aorta with an anastomosis of the great saphenous vein in a 61-year-old female with a history of multiple open-heart procedures. Thirty years earlier, she underwent aortic valve replacement and coronary artery bypass surgery for aortic regurgitation, and right coronary ostial stenosis. Eleven years after surgery, an ascending aortic aneurysm was found and Bentall's surgery was performed. Multiple open thoracotomies were subsequently performed. Postoperatively, a pseudoaneurysm was found at the anastomosis between the ascending aorta and the great saphenous vein. The patient was transferred to the emergency room owing to hemoptysis and was diagnosed with a ruptured pseudoaneurysm at the anastomosis of the ascending aorta and the great saphenous vein. By inserting a stent graft into the ascending aorta, we avoided further complications and her prognosis was good. She was discharged on postoperative day 18 and did not experience any end leak for a year. Thoracic endovascular aortic repair in the ascending aorta is a minimally invasive procedure that may be useful for high-risk patients.

Right Parasternal Vertical Approach for Tricuspid Valve Replacement in Repeated Cardiac Surgery / 日本心臓血管外科学会雑誌

Median sternotomy is the most common approach used for repeated cardiac surgery, but it is associated with potential risks such as cardiac injury. Patients with valvular heart disease may be especially prone to these complications because of severe cardiomegaly and adherence of the heart to the posterior sternum. To avoid these risks, we began using a right thoracotomy approach, performed through a right parasternal vertical incision, which is better than the traditional right anterolateral thoracotomy, in selected patients. A 50-year-old woman who had undergone 3 previous cardiac operations at another hospital presented with remarkable cardiomegaly. We performed successful tricuspid valve replacement for tricuspid stenosis, through a right parasternal vertical incision. This approach provides excellent exposure of the tricuspid valve with minimal need for dissection. The right parasternal vertical incision has 3 main advantages over right anterolateral thoracotomy; first, it provides an excellent view of the right atrium underneath the wound; second, it allows for easy cannulation because of the position of the spine; and third, the skin incision is smaller. In conclusion, we think that the parasternal vertical incision is a better approach for repeated cardiac surgery than anterolateral thoracotomy because it provides a better operative view and an easier maneuver.