Persistent Fifth Aortic Arch with Coarctation

Persistent fifth aortic arch (PFAA) is a rare congenital anomaly of the aortic arch frequently associated with other cardiovascular anomalies, such as tetralogy of Fallot and aortic arch coarctation or interruption. We report the case of a neonate with PFAA with coarctation who successfully underwent surgical repair.

Isolation of the Left Subclavian Artery with Right Aortic Arch in Association with Bilateral Ductus Arteriosus and Ventricular Septal Defect

Right aortic arch with isolation of the left subclavian artery is a rare anomaly. The incidence of bilateral ductus arteriosus is sporadic, and a right aortic arch with isolation of the left subclavian artery in association with bilateral ductus arteriosus is therefore extremely rare. Since the symptoms and signs of isolation of the left subclavian artery can include the absence or underdevelopment of the left arm, subclavian steal syndrome, or pulmonary artery steal syndrome, the proper therapeutic approach is controversial. We report a case in which surgical reconstruction was used to treat isolation of the left subclavian artery with right aortic arch in association with bilateral ductus arteriosus and a ventricular septal defect.

Abnormal Origin of the Left Subclavian Artery from the Left Pulmonary Artery in a Patient with Double Outlet Right Ventricle

Anomalous aortic origin of the left subclavian artery (LSCA) from the left pulmonary artery (LPA) is a rare congenital cardiac malformation. We describe a case of LSCA from the LPA via ductus arteriosus in association with a double-outlet right ventricle, which never has been reported previously in Korea.

Extended Aortic Arch Replacement Through the L-Incision Approach

There are various methods for approaching the aortic arch, such as median sternotomy or lateral thoracotomy. However, accessing the site of distal anastomosis is problematic when the distal arch is extensively involved. We report a case of extended aortic arch replacement and coronary artery bypass through the L-incision approach.

Extended Aortic Arch Replacement Through the L-Incision Approach

There are various methods for approaching the aortic arch, such as median sternotomy or lateral thoracotomy. However, accessing the site of distal anastomosis is problematic when the distal arch is extensively involved. We report a case of extended aortic arch replacement and coronary artery bypass through the L-incision approach.

Complete Vascular Ring Caused by Kommerell's Diverticulum and Right Aortic Arch with Mirror Image Branching

Vascular ring, caused by Kommerell's diverticulum and ligamentum arteriosum, in a patient with right aortic arch and mirror image branching is extremely rare. A 10-month-old boy with coughing and stridor was diagnosed as having tracheo-esophageal stenosis, which is caused by a vascular ring with Kommerell's diverticulum, ligamentum arteriosum, right aortic arch, and mirror image branching. Kommerell's diverticulum was successfully resected via a left thoracotomy. The patient has been free from tracheo-esophageal stenosis for a year after the surgery.

Aortic Arch Debranching and Antegrade Stent Graft Placement in an Expanding Distal Dissecting Aneurysm after Repair of an Acute Type I Aortic Dissection / 대한흉부외과학회지

Endovascular treatment of the aortic aneurysm with a stent graft is rapidly evolving. We describe here a case of hybrid TEVAR (thoracic endovascular aortic repair) in which the stent grafts were placed in the aortic arch after debranching of the arch vessels. The patient had undergone ascending aorta replacement for acute type I aortic dissection 2.5 years earlier. The aneurysmal change of the distal dissection progressed with time. A provisional bypass surgery from the ascending aorta to the innominate artery and left carotid artery was performed and then stent grafts were inserted via an antegrade route that covered the whole aortic arch and proximal descending thoracic aorta.

Stent-graft Insertion in High Risk Patients with Aortic Dissection Including Intimal Tear of the Aortic Isthmus: A case report / 대한흉부외과학회지

Recently, stent-graft insertion has been widely used along with surgery for treatment of thoracic and abdominal aortic aneurysm. However, use of stent-graft insertion is controversial in descending aortic dissection. We report here on our experience of a patient who received a stent-graft for descending aortic dissection that nearly ruptured. Based on CT findings at three months follow up, results were satisfactory.

Hybrid Endovascular Repair for Type I Endoleak after Stent Grafting of Chronic Stanford Type B Aortic Dissection: A case report / 대한흉부외과학회지

A 67 years old male patient was admitted with back pain that had recurred from 6 months previously. Eleven years previously, he underwent stent grafting at the descending thoracic aorta for a chronic Stanford type B aortic dissection. The preoperative computed tomography showed aortic dissection from the origin of the left subclavian artery to the bifurcation of the abdominal aorta, and there was a type I endoleak at the proximal portion of the stent graft and aneurysmal dilatation of the descending aorta. A hybrid endovascular repair was successfully performed, and this involved debranching and rerouting the aortic arch vessels under extracorporeal cardiopulmonary bypass and then this was followed 13 days later by stenting in the ascending aorta, the aortic arch and the descending aorta. The postoperative computed tomography showed complete exclusion of the type I endoleak. After discharge, he has been followed up for 8 months without any problems.

Early and Midterm Results of Hybrid Endovascular Repair for Thoracic Aortic Disease / 대한흉부외과학회지

BACKGROUND: A hybrid procedure using an open surgical extra-anatomic bypass of aortic arch vessels and thoracic endovascular aortic repair (TEVAR) is less invasive than open surgery, and provides a suitable proximal landing zone. Here we report our experience with a hybrid TEVAR procedure at a single center. MATERIAL AND METHOD: We retrospectively reviewed consecutive patients with thoracic aortic disease who received a hybrid TEVAR procedure between August 2008 and January 2010. Patients' data were prospectively collected and mean follow-up was 10.8+/-5.5 months (range 3~20). RESULT: Nine patients (7 males and 2 females) with a mean age of 63.8+/-15.8 years (range 38~84) underwent a hybrid procedure. Five patients had an arch or a proximal descending aortic aneurysm, two had a dissecting aneurysm of the descending aorta, and two had an aneurysm of the ascending arch and descending aorta. Mean expected mortality calculated by logistic EuroSCORE was 21%. Six patients underwent debranching and rerouting from ascending aorta to arch vessels, 2 had carotid-carotid bypass grafting, and 1 underwent carotid-axillary bypass grafting. Mean operation time was 221.4+/-84.0 min (range 94~364). Deployment success of endovascular stent grafting was 100% with no endoleak on completion angiography. There was no mortality, and a small embolism in the branch of the right opthalmic artery in one patient. During follow-up, one intervention was required for the endoleak. Actuarial survival at 20 months was 100%. CONCLUSION: Early and mid-term results are encouraging and suggest that hybrid TEVAR procedures are less invasive and safer and represent an effective technique for treating thoracic aortic disease.

Hybrid Procedure for Aortic Arch Aneurysm: Arch Vessels Debranching and Thoracic Endovascular Aortic Repair?: 2 case reports / 대한흉부외과학회지

Conventional surgery for aortic arch aneurysms have many postoperative complications and a high mortality rate due to prolonged cardiopulmonary bypass time, especially in high risk patients. In this report, we present two cases of a hybrid procedure that involves open brachiocephalic bypass with concomitant endovascular arch stent grafting in high risk patients with distal aortic arch aneurysm.

Aortic Arch Aneurysm Repair using a Prosthetic Graft with a Pre-mounted Distal Stent (Frozen Elephant Trunk) / 대한흉부외과학회지

Difficulty in exposing anastomotic sites is a frequently encountered problem during surgical repair of a distal aortic arch aneurysm via median sternotomy or lateral thoracotomy. Endovascular repair has the limitation that it usually requires surgical rerouting of some of the brachiocephalic branches in order to get sufficient length for proximal fixation of the stent-graft. To take advantage of each approach, we fixed the distal end of the prosthetic graft by means of a pre-mounted metallic stent instead of performing conventional surgical anastomosis during the repair of distal arch aneurysms with using median sternotomy and hypothermic circulatory arrest. We report here on our experience with such 3 patients.

Hybrid Procedure for Aortic Arch Repair: Arch Vessels Debranching with Supraaortic Revascularization Followed by Endovascular Aortic Stent Grafting / 대한흉부외과학회지

Aortic arch aneurysm generally requires an urgent treatment due to the risk of catastrophic aortic rupture. However, conventional surgery for aortic arch repair still carries significant risks of postoperative morbidity and mortality, especially in patients with old age. In an effort to correct the aortic pathology while minimizing the risks of complications, we performed a hybrid technique which comprises the off pump arch vessels debranching and endocascular aortic stent grafting in an 86-old male patient with an aortic arch aneurysm.

Twelve Years of Experience with Vascular Ring Surgery / 대한흉부외과학회지

BACKGROUND: Vascular ring is a rare anomaly of the aortic arch. We did surgical repair procedures on 16 cases of vascular ring over the past 12 years. This article reviews our results. MATERIAL AND METHOD: Between 1995 and 2007, 16 patients (5 with double aortic arch, 7 with right aortic arch-left ligamentum, 4 with pulmonary artery sling) underwent surgical repair. Mean age at the time of the operation were as follows: double aortic arch, 5.7+/-5.5 years; right aortic arch-left ligamentum, 6.1+/-13.4 years; pulmonary artery sling, 2.9+/-2.6 years. Five patients (71%) with right aortic arch-left ligamentum had an associated Kommerell's diverticulum. Two patients (40%) with double aortic arch, 2 patients (28.6%) with right aortic arch-left ligament and 4 patients (100%) with pulmonary artery sling had associated airway stenosis. Cardiac anomalies were present in 8 of 16 patients. RESULT: There was no peri-operative or post-operative mortality. The mean hospital stay was 27.1+/-38.2 days. None of our patients underwent reoperation. CONCLUSION: Vascular ring is rare, but, it needs surgical correction. It is important to suspect the diagnosis and to validate with echocardiography. Preoperative and postoperative computed tomography and bronchoscopy are useful to evaluate the airway and surrounding structures.

Ruptured Penetrating Atherosclerotic Ulcer of the Aortic Arch in a Patient with a Previous History of Replacing the Descending Thoracic Aorta / 대한흉부외과학회지

Aortic disease usually recurs after aortic surgery in the form a new aneurysm distal to the previous operation site, and finding a penetrating atherosclerotic ulcer proximal to the previous operation site has rarely been reported. We report here on a case of successful patch repair of a ruptured penetrating ulcer in the distal aortic arch, and this developed late after replacement of the descending thoracic aorta.

Clinical Result of Aortic Arch Replacement using Antegrade Brain Perfusion Via Right Axillary Artery / 대한흉부외과학회지

BACKGROUND: Cerebral protection is one of the most important procedures during aortic arch surgery. We can minimize neurological complications through short period of total circulatory arrest and resuming of brain perfusion. We evaluated 11 patients who underwent arch replacement using antegrade brain perfusion via right axillary artery. MATERIAL AND METHOD: Between July 2004 and July 2006, 11 patients (male 9, female 2) underwent aortic arch replacement with antegrade brain perfusion via right axillary artery. Preoperative diagnosis was listed; 5 type A aortic dissections (5/11, 45.5%), 5 aortic aneurysms (5/11, 45.5%) and 1 type A IMH (intramural hematoma, 1/11, 9%). The mean age at the time of operation was 60.3+/-12.8 years. For antegrade brain perfusion, we performed right axillary artery cannulation in all patients. Retrograde brain perfusion was used briefly during total circulatory arrest. RESULT: The mean total circulatory arrest time was 31.1+/-16.9 minutes and the mean retrograde brain perfusion time was 21+/-17.8 minutes. Mean antegrade brain perfusion time was 77.9+/-17.5 (43~101) minutes. We had neither operative mortality nor permanent neurological complications. CONCLUSION: By means of antegrade brain perfusion via right axillary artery, that could lead to decrease circulatory arrest time and minimize damages to severely atheromatous arch vessels, we can expect to reduce neurological complications after aortic arch replacement. Further investigation with large patient populations will be required.

Ruptured Penetrating Atherosclerotic Ulcer Involving the Aortic Arch: A case report / 대한흉부외과학회지

Penetrating atherosclerotic ulcer involving the aortic arch has rarely been reported on in the literature. Acute rupture of a penetrating atherosclerotic ulcer involving the distal arch and the proximal descending thoracic aorta was found in a 78-year-old male, and he originally presented with acute-onset shoulder pain and hoarseness. Patch repair of the perforated arch and the proximal descending thoracic aorta was successfully done under total circulatory arrest.

Comparison of the Mid-term Changes at the Remnant Distal Aorta after Aortic Arch Replacement or Ascending Aortic Replacement for Treating Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: Replacing the ascending aorta is a standard surgical option for treating acute type A aortic dissection. But replacing the aortic arch has recently been reported as an acceptable procedure for this disease. We compared the effects of aortic arch replacement for treating acute type A aortic dissection with the effects of ascending aortic replacement. MATERIAL AND METHOD: From 2002 to 2006, 25 patients underwent surgical treatment for acute type A aortic dissection. 12 patients underwent ascending aortic replacement and 13 patients underwent aortic arch replacement. Among the aortic arch group, an additional distal stent-graft was inserted during the operation in 5 patients. 19 patients (11 arch replaced patients and 8 ascending aortic replaced patients) were followed up at the out patient clinic for an average of 756+/-373 days. All the patients underwent CT scanning and we analyzed their distal aortic segments. RESULT: 4 patients who underwent ascending aortic replacement died, so the overall mortality rate was 16%. Among the 11 long term followed-up arch replacement patients, 2 patients (18.1%) developed distal aortic dilatation and one of them underwent thoracoabdominal aortic replacement later on. However, among the 8 the ascending aortic replaced patients, 5 patients (62.5%) developed distal aortic dilatation. CONCLUSION: Aortic arch replacement is one of the safe options for treating acute type A aortic dissection. Aortic arch replacement for treating acute type A aortic dissection could contribute to a reduced distal aortic dilatation rate and fewer secondary aortic procedures.

Analysis of the Causes of and Risk Factors for Mortality in the Surgical Repair of Interrupted Aortic Arch / 대한흉부외과학회지

BACKGROUND: Interrupted aortic arch is a rare congenital heart anomaly which still shows high surgical mortality. In this study, we investigated the causes of and the risk factors for mortality to improve the surgical outcomes for this difficult disease entity. MATERIAL AND METHOD: From 1984 to 2004, 42 patients diagnosed as IAA were reviewed retrospectively. Age, body weight at operation, preoperative diagnosis, preoperative PGE 1 requirement, type of interrupted aortic arch, degree of left ventricular outflow stenosis, CPB time, and ACC time were the possible risk factors for mortality. RESULT: There were 14 hospital deaths. Preoperative use of PGE1, need for circulartory assist and aortic cross clamp time proved to be positive risk factors for mortality on univariate analysis. Preoperative left ventricular outflow stenosis was considered a risk factor for mortality but it did not show statistical significance (p-value=0.61). Causes of death included hypoxia due to pulmonary banding, left ventricular outtract stenosis, infection, mitral valve regurgitation, long cardiopulmonary bypass time and failure of coronary transfer failure in TGA patients. CONCLUSION: In this study, we demonstrated that surgical mortality is still high due to the risk factors including preoperative status and long operative time. However preoperative subaortic dimension was not related statistically to operative death statistically. Adequate preoperative management and short operation time are mandatory for better survival outcome.

Extraanatomic Ascending-to-Descending Aorta Bypass Graft for Atypical Coarctation: A case report / 대한흉부외과학회지

Under median sternotomy and left thoracotomy, extra-anatomic aorta bypass between ascending aorta and descending thoracic aorta without cardiopulmonary bypass support has been done effectively and easily without complications for a selected case of atypical coarctation associated with hypoplasia of aortic arch. It should be considered as an alternative operative technique for complex aortic arch reconstruction.