ABSTRACT
@#The conventional total arch replacement (cTAR) with frozen elephant trunk implantation is commonly regarded as the gold standard for aortic pathologies involving ascending aorta and proximal aortic arch. By combining open supra-aortic vessels debranching and emerging endovascular technologies, hybrid arch repair (HAR) has been increasingly performed as a promising alternative in risky patients with comorbidities and frailties. Nevertheless, the advantages or disadvantages of hybrid arch procedures and cTAR in terms of survival and related outcomes remain controversial. This study is aimed to briefly review the role and results of HAR in the management of aortic arch pathology in comparison of contemporary cTAR.
ABSTRACT
During aortic arch replacement in response to an aortic arch aneurysm sealed rupture, we experienced a case in which weaning from cardio-pulmonary bypass (CPB) became difficult, and pulmonary artery stenosis developed due to expanded hematoma. A 77-year-old man was raced to our hospital due to subjective symptom of chest/back pain. With a recognition of aortic arch aneurysm and hematoma around the aneurysm, it was diagnosed as an aortic arch aneurysm sealed rupture. Even though an elective aortic arch replacement was implemented using an open stent graft, reduction in blood pressure and poor oxygenation was observed at the process of CPB weaning. As a result of intraoperative pulmonary arteriography, severe stenosis was revealed on both left and right pulmonary arteries. With placement of a self-expanding stent, weaning from CPB was successfully completed. Being transferred to other hospital on day 60 after the surgery in order to continue rehabilitation, the man visits our hospital as an outpatient on his own as of now. As it is considered to be a rare case that weaning from CPB was successfully performed by pulmonary stenting in response to progressed intraoperative pulmonary artery stenosis caused by expanded hematoma after heparin administration, the details are reported here.
ABSTRACT
<p>Aortopulmonary fistula with an arch aortic aneurysm is a rare disease that is difficult to diagnose and often presents with sudden, life-threatening heart failure. Here we report a case of aortopulmonary fistula for which we performed a thoracic endovascular aortic repair (TEVAR) with favorable results. A 79-year-old man presented with slurring of speech and body malaise at a neighborhood clinic. A distal arch aortic aneurysm was detected on chest computed tomography (CT) scans, and the patient was referred to our hospital for further management. We identified a saccular aneurysm and the dilated pulmonary artery, with maximum vessel diameters of 80 and 38 mm, respectively, on preoperative chest CT scans. He was diagnosed with an impending aortic rupture and a TEVAR was performed after preparing for a cervical ramification bypass. Intraoperatively, the aortopulmonary fistula had invaded the pulmonary artery, and the shunt created by the invasion was responsible for the sudden exacerbation of heart failure symptoms in the patient. The diameter of the saccular lump did not increase in the postoperative CT and follow-up visits were scheduled for subsequent monitoring. In the absence of significant complications and with improvement of heart failure symptoms, the patient was discharged from our hospital on the 37th postoperative day. He was later transferred to a neighborhood clinic for rehabilitation and subsequently discharged for further recuperation at home in the fifth postoperative month.</p>
ABSTRACT
AbstractThe authors report the case of a 55-year-old female, hypertensive, smoker patient presenting with dysphonia, dysphagia and persistent dry cough. Laryngoscopy diagnosed left vocal cord paralysis. Computed tomography demonstrated saccular aneurysm of the inferior wall of the aortic arch, stretching the left recurrent laryngeal nerve, a finding compatible with Ortner’s syndrome.
ResumoRelatamos um caso de paciente do sexo feminino, 55 anos, hipertensa, tabagista, apresentando disfonia, disfagia e tosse seca persistente. À videolaringoscopia foi observada paralisia da prega vocal esquerda. A tomografia computadorizada mostrou aneurisma sacular da parede inferior do arco aórtico, no local de deflexão do nervo laríngeo recorrente, permitindo diagnosticar a síndrome de Ortner.
ABSTRACT
Acute aortopulmonary artery fistula is a rare but potentially fatal disorder. We encountered a case in which this disorder was successfully treated by urgent total arch graft replacement and repair of the left pulmonary artery. A 74-year-old man was referred to Shizuoka City Hospital with a 2-day history of worsening dyspnea and thoracic aortic aneurysm. The patient had a history of hypertension and dyslipidemia. Physical examination showed diastolic hypotension, marked peripheral coldness, and systolic murmur. Arterial blood gas analysis showed severe metabolic acidosis with base excess of −16 mmol/<i>l</i>. Contrast-enhanced computed tomography (CT) revealed an aortic arch aneurysm on the lesser curvature, almost obstructing the left pulmonary artery. A Swan-Ganz catheter study confirmed severe low-output syndrome and uncompensated congestive heart failure. After amelioration of critically ill conditions with dopamine, milrinone, and carperitide, oxymetry revealed significant left-to-right shunt with Qp/Qs＝3.2 at the pulmonary artery level. Acute aortopulmonary artery fistula was diagnosed and urgent surgery was planned. Transesophageal echocardiography showed systolic shunt flow from the aneurysm into the left pulmonary artery. Surgery was performed through a median sternotomy. Aortic arch graft replacement with a 24-mm Dacron graft and repair of the left pulmonary artery with an equine pericardial patch were accomplished under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Flooding of pulmonary circulation until circulatory arrest was prevented by manual control through the main pulmonary artery incision. Postoperative recovery was uneventful, and the patient is doing well at one year postoperatively.
ABSTRACT
The surgical treatments for aortic arch aneurysm are thought to be very invasive procedures, and high morbidity and mortality rates have been reported after aortic arch aneurysm operations. Many surgeons currently prefer the insertion of a stent-graft rather than an operation for treating an aortic arch aneurysm and if needed, with bypass of the subclavian or carotid arteries, which is called the 'hybrid method'. We managed one patient with an aortic arch aneurysm by using the hybrid method, and so we report on this case with a review of the relevant literature.
Subject(s)
Humans , Aneurysm , Aorta, Thoracic , Aortic Aneurysm, Thoracic , Carotid Arteries , Chimera , StentsABSTRACT
Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.
Subject(s)
Humans , Aneurysm , Aorta, Thoracic , Brain Ischemia , Circulatory Arrest, Deep Hypothermia Induced , Disulfiram , Hemodilution , Oximetry , Spectrum Analysis , Wit and Humor as TopicABSTRACT
Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.