Right Subclavian Artery Bypass Grafting and Replacement of Two-Thirds of the Aortic Arch for a Rare Case Involving Aneurysm of the Right Subclavian Artery with Dissection / 日本心臓血管外科学会雑誌

A 69-year-old man was referred to our hospital because of a right upper mediastinal mass observed on chest roentgenogram. Computed tomography showed a dissecting aneurysm of the right subclavian artery and dissection of the ascending aorta. Furthermore, the ascending aorta was dilated. We subsequently reconstructed the right subclavian artery with a bypass graft and replaced the ascending aorta. Two-thirds of the aortic arch was placed in deep hypothermic circulatory arrest with retrograde cerebral perfusion. His postoperative course was uneventful with no neurological complications. While subclavian artery aneurysms are relatively rare in comparison to other peripheral artery aneurysms, subclavian artery aneurysms with aortic dissections are even rarer. The most important concerns during subclavian artery aneurysm repair are the method of surgical approach and the maintenance of sufficient cerebral flow. We suggested that deep hypothermic circulatory arrest with retrograde cerebral perfusion might prove useful in cases involving an intramural thrombus adherent to cerebral vessels. Therefore, patients with subclavian artery aneurysms must undergo extensive preoperative evaluation.

Ten Years' Experience of Aortic Annulus Ectasia and Ascending-Arch Aortic Aneurysm Cases in Adult Congenital Heart Disease / 日本心臓血管外科学会雑誌

<b>Background</b> : The improvement in surgical results for congenital heart disease has resulted in an increase in the number of adult congenital heart disease (ACHD) cases. Some ACHD patients are known to develop thoracic aortic aneurysm (TAA) at a young age, so we examined TAA in ACHD patients presenting at our institute over a 10-year interval. <b>Methods</b> : From 2002 to 2011, we performed 32 cases of surgery for TAA in ACHD patients. We excluded 5 cases of adult bicuspid aortic valve, 2 of TAA with untreated congenital heart disease (CHD), 1 of Marfan syndrome with CHD, and 9 of coarctation of the aorta (CoA) repair for the same site ; 15 patients were included. <b>Results</b> : The male/female ratio was 13/2, and the age of reoperation was 33.3±10.8 years. The 15 ACHD patients included 5 cases of the tetralogy of Fallot (TOF), 4 of congenital aortic stenosis (AS), 3 of ventricular septal defect (VSD), and 1 of each CoA complex, polysplenia/double outlet right ventricle (DORV), and polysplenia/corrected transposition of the great arteries (cTGA). Twelve cases of root dilatation and 2 of ascending aortic aneurysm were observed and 10 cases were concomitant with moderate to severe aortic regurgitation. Thirteen cases underwent elective surgery and the other two cases were emergency surgeries : a Bentall procedure for type 2 acute aortic dissection of polysplenia/DORV, and a Bentall and right ventricular outflow reconstruction (RVOTR) for ascending aorta/right ventricle rupture due to Konno patch detachment in congenital AS. The 13 elective cases included 11 cases of Bentall procedure, 1 of ascending aorta/hemi arch replacement, and 1 of ascending aorta replacement. Concomitant procedures were 1 case of aortic valve replacement, 1 of mitral valve replacement, 1 of subaortic stenosis release, and 2 of RVOTR. Operation time was 572.8+/-101.4 min, cardiopulmonary bypass time was 295.8+/-100.2 min, and aorta clamp time was 188.1+/-58.8 min. One hospital death was observed in 1 emergency case due to methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) sepsis, but no 30-day mortality was observed. Intensive care unit (ICU) stay was 9.4+/-10.1 days and hospital stay was 34.4+/-18.2 days. <b>Conclusion</b> : The most common ACHD found during TAA surgery in our institute was Tetralogy of Fallot. ACHD had various complications and restrictions for surgery but TAA surgery in ACHD patients was safe and feasible.

A Giant Celiac Aneurysm with Acute Aortic Dissection and Idiopathic Thrombocytonenic Purpura / 日本心臓血管外科学会雑誌

We report a rare case of a giant celiac aneurysm complicated with nosocomial acute aortic dissection and idiopathic thrombocytonenic purpura (ITP). A 75-year-old man with ITP complained of abdominal swelling. Enhanced computed tomography (CT) showed a giant celiac aneurysm 72 mm in size. Surgery repair was scheduled and platelet count increased by intravenous administration of immunoglobulin. After admission, he complained of back pain. CT showed aortic dissection (DeBakey classification : IIIb) and a celiac aneurysm enlarged to 78 mm. He underwent surgical repair for a giant celiac aneurysm and splenectomy after management with medial therapy.

Reoperation for Valvular Surgery and Thoracic Aortic Aneurysm Repair with Functioning IMA Grafts after Previous CABG / 日本心臓血管外科学会雑誌

The use of the internal mammary artery (IMA) is now routine in most coronary artery bypass grafting (CABG) because of its improved long-term patency and survival. A small but important percentage of these patients will require valve surgery and thoracic aortic aneurysm repair following CABG. These operations present a challenging problem for the cardiac surgeon because of difficulties regarding approach, dissection around the IMA and optimal myocardial protection. We investigated surgical results and the effectiveness of various methods of myocardial protection in 8 patients who underwent reoperations between December 1983 and June 2005. The mortality was 13%. There were 2 perioperative myocardial infarctions (25%), 6 cases of prolonged ventilation (75%), 3 cases of low output syndrome (38%), 1 case of acute renal failure (13%) and 1 case of sepsis (13%). We carried out resternotomy for 6 patients without any hospital death or perioperative myocardial infarction. Our reoperation approach had acceptable risk control with resternotomy, avoidance of dissecting the IMA and hypothermic perfusion.

A Case of Aortic Replacement for a Patient with Bilateral Internal Carotid Stenoses / 日本心臓血管外科学会雑誌

A 71-year-old man was given a diagnosis of saccular aneurysm of the aortic arch (maximum 48mm in diameter) at the age of 68. When he was 69 years old, he began to take steroids for autoimmune hepatitis (AIH). The following year, the aneurysm was enlarged to 52mm. Further examinations showed the aneurysm to extend to the ostium of the left subclavian artery. Since he had transient ischemic attacks, ultrasonography of the carotid arteries was performed. Bilateral internal carotid stenoses were detected, however, cold Xe CT showed an almost normal pattern of cerebral blood flow. We decided that operation was feasible using retrograde cerebral perfusion (RCP). Liver dysfunction due to AIH improved, and his steroid dosage was tapered. Using RCP, the no-touch technique and the elephant trunk procedure, he underwent the replacement of ascending aorta and aortic arch and was discharged without major complications. RCP and the no-touch technique might enable safer operations on patients with carotid stenoses.

Surgical Strategy for Thoracic Aortic Aneurysm with Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

We evaluated the surgical strategy for thoracic aortic aneurysm associated with abdominal aortic aneurysm. From January 1982 to March 1999, 24 consecutive patients underwent surgical treatment for thoracic aortic aneurysm with abdominal aortic aneurysm. Staged operation was performed if one was only slightly dilated, but extensive operation was needed if the size of both aneurysms was greater than 6cm. In cases of thoracic aortic aneurysm with abdominal aortic aneurysm up to 4cm in size, surgical treatment was performed only for the thoracic aortic aneurysm. Circulatory support during operation was established from the ascending aorta, and circulatory arrest with deep hypothermia and retrograde cerebral perfusion were used for brain protection during surgery for thoracic aortic arch aneurysm. Hospital mortality was 12.5% (3/24 cases). The causes of death were cerebral infarction and respiratory failure. Antegrade systemic perfusion and aortic no-touch technique were an effective method of surgery for thoracic aortic aneurysm with abdominal aortic aneurysm to avoid perioperative embolism and major complications. We successfully performed staged operation, but regular radiographic follow-up was needed.

Two Cases of Infected Aortic Abdominal Aneurysm with Spondylodiskitis / 日本心臓血管外科学会雑誌

We encountered two cases of infected aortic abdominal aneurysm with spondylodiskitis. Both cases were diagnosed on the basis of fever, back pain and pulsatile abdominal mass. A 69-year-old man, case 1, underwent <i>in situ</i> reconstruction 1 year from the onset, because the infection was controllable by antibiotics and he had diabetes mellitus. A 68-year-old man, case 2, underwent operation while his infection was still active, because of paralysis of the bilateral lower extremities, aggravated by invasion of the vertebrae by the abscess. To prevent artificial graft infection, he underwent axillo-femoral bypass, which was extra-anatomical reconstruction, after the infected aneurysm and vertebrae were removed during aortic clamping above the aneurysm and bilateral common iliac arteries. Each stump was sutured and anterior fixation of the vertebrae was performed using an iliac bone graft. The postoperative course of both patients was successful. These cases suggest that the timing and procedure of the operation for infected aortic abdominal aneurysm with spondylodiskitis should be decided depending on the activity of infection, complications, age and activity of daily life of patients.

Sternotomy Approach in a Case of Giant Ascending Aortic Aneurysm and Annuloaortic Ectasia Previously Operated for Pure Pulmonary Stenosis / 日本心臓血管外科学会雑誌

A 29-year-old man, who had undergone valvotomy for pure pulmonary stenosis at 6 months of age, was admitted to our institution for surgical treatment of a giant ascending aortic aneurysm and annuloaortic ectasia. Chest MRI revealed a 14-cm ascending aneurysm in contact with the sternum. After establishing femoro-femoral bypass for hypothermia, a left lateral thoracotomy was perfomed at the 4th intercostal space. Pulmonary artery cannulation was performed for left heart venting, and the proximal aortic arch was dissected for aortic cross-clamping. Median sternotomy was performed under circulatory arrest at 18°C and the aortic arch was opened. Under retrograde cerebral perfusion, the proximal arch was replaced by an artificial graft, and then aortic root replacement was completed using a composite graft under CPB. The postoperative course was uneventful, and the patient was discharged on the 37th postoperative day. He has been well without any complications. This case suggests that our method of approach to the giant aortic aneurysm with sternal adhesion and aortic regurgitation, and the use of extracorporeal circulation in view of the annuloaortic ectasia is effective and safe in case of reoperation.

Surgical Treatment for Ruptured Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

Forty-four cases of ruptured abdominal aortic aneurysm were treated between January 1980 and December 1995. We classified the cases into three groups: Group I, 1980-1984; Group II, 1985-1989; and Group III, 1990-1995 and evaluated the surgical results, the preoperative states, the bleeding and blood transfusion volume and so on. The surgical results have improved every year and there were no surgical deaths during the past seven years. Most of the causes of previous surgical deaths were DIC (4 cases) and renal failure (3 cases). The volume of intraoperative bleeding was 7227.3±3293.4ml in Group I, 4176.0±2577.9ml in Group II and 1781.9±1877.0ml in Group III. The volume of intraoperative blood transfusion was 6975.5±2711.6ml in Group I, 4826.7±2596.6ml in Group II and 3542.4±1561.5ml in Group III. We decreased the volume of intraoperative blood transfusion significantly in Group III by using a Cell Saver. The surgical results have improved significantly due to the decrease of bleeding and blood transfusion under the rapid control of bleeding and the autotransfusion of shed blood using the Cell Saver. The technique of postoperative care also contributed to the more satisfactory results.

Effectiveness of Left Heart Bypass Combined with Oxygenation in the Surgical Treatment of Thoracoabdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

The surgical results of 9 patients (group II) who were treated for thoracoabdominal aneurysm using left heart bypass combined with oxygenation were compared to those of 16 patients (group I) using left heart bypass without oxygenation. The left heart bypass time in group II was longer than that in group I, and the operations performed in group II were more extensive with more intercostal and lumbar arteries being reconstructed than those in group I. Nevertheless, bleeding associated with transfusion was less in group II than in group I. Intraoperatively, hypothermia and hypoxemia developed in 44% and 31%, respectively of group I, whereas neither of these conditions occurred in group II. There were three operative deaths in group I, compared with one in group II. Paraplegia was encountered in one patient of group I, but in none of the patients in group II. There were a few patients with respiratory failure or other organ failures in both groups. Our results showed that left heart bypass combined with oxygenation offered more stable and effective respiratory as well as circulatory support for a long duration compared to conventional left heart bypass without oxygenation in the surgical treatment of thoracoabdominal aortic aneurysm.

Composite Graft Replacement of the Aortic Root Using a New St. Jude Medical Aortic Valve Graft Prosthesis / 日本心臓血管外科学会雑誌

The new St. Jude Medical aortic valve graft prosthesis was evaluated for composite graft replacement of the aortic root in 32 patients at three institutions. This study was performed in conformity with the Japanese Drugs, Cosmetics and Medical Instruments Act. The grafts were preclotted with blood of serum albumin: coronary artery reconstruction was performed employing the classical Bentall procedure (4 cases), Cabrol's procedure (14 cases), the interposition graft technique (8 cases) or the button technique (6 cases); concomitantly the aortic arch was replaced in one patient, and the mitral valve was replaced in two patients. One early death (3%) occurred as the result of shock sustained prior to establishing cardiopulmonary bypass. Postoperative complications included perivalvular leakage (one case), perioperative myocardial infarction (two cases), hepatitis (one case). There were no late deaths and no complications related to the SJM valve graft prosthesis. The SJM valve graft prosthesis is a safe and reliable prosthesis for use as a composite graft replacement of the aortic root.

A Case of Catastrophic Pulmonary Bleeding That Occurred after Extensive graft Replacement of the Ascending, Transverse Aortic Arch and the Descending Thoracic Aorta / 日本心臓血管外科学会雑誌

This report describes 5 patients in whom extensive graft replacement was performed using a combination of median sternotomy with antero- or postero-lateral thoracotomy: 3 of them received replacement from the ascending to the descending thoracic aorta through the transverse aortic arch, and 2 of them received replacement from the transverse aortic arch to the descending thoracic aorta. Four of the 5 patients had catastrophic pulmonary bleeding during surgery and died immediately after the surgery. Histological investigations on 3 of the 5 patients revealed the presence of bleeding in bilateral alveola; edema in the pulmonary parenchymal tissues; and heavy bleeding extensively in the lung which was especially intensive in the pulmonary hilum and caused necrosis of that region in one case. We presume that long periods of total heparinization (extracorporeal circulation time>240min) performed during lateral thoracotomy, were the most important cause of the pulmonary bleeding. Other factors that could cause pulmonary bleeding are (i) avoidance of use of a double lumen endotracheal tube, (ii) pulmonary congestion due to heart failure during surgery, and (iii) pulmonary injury caused by surgical manipulation. We therefore consider that extensive graft replacement of the thoracic aorta through lateral thoracotomy using a pump-oxygenator, is associated with a high risk of pulmonary bleeding when it takes longer than 240min, and it is essential to perform the graft replacement in the possible shortest time.