Preceding Re-entry Closure for Chronic Thoracic Aortic Dissection in a Patient with Marfan Syndrome / 日本心臓血管外科学会雑誌

<p>A 42 year-old woman with Marfan syndrome, who had replacement of the ascending aorta for acute aortic dissection several years ago, was found to have distal aortic arch aneurysm. The aneurysm had small entries at cervical arterial branches and large re-entry at the left external iliac artery. It was necessary to perform two-staged operation Bentall procedure with total arch replacement and abdominal aortic replacement with re-entry closure. It was usually performed with a primary entry closure for chronic aortic dissection, but massive invasion was expected. We performed catheter angiography for entry and re-entry, and decided to perform preceding re-entry closure. First, we underwent replacement of the abdominal aorta, and then successfully performed the Bentall procedure with total aortic arch replacement. The catheter angiography was useful for decision-making for medical treatment.</p>

Sequential Hybrid Repair of Aorta and Bilateral Common Iliac Arteries Secondary to Chronic Aortic Dissection with Extensive Aneurysmal Degeneration in a Marfan Patient

Marfan syndrome is a connective tissue disorder associated with aortic dissection, aneurysmal degeneration and rupture. These cardiovascular complications represent the main cause of mortality, therefore repair is indicated. We present a 35-year-old woman who experienced acute onset of chest pain. Her imaging revealed a chronic DeBakey type I dissection with aortic root dilation and descending thoracic aneurysmal degeneration. She underwent a Bentall procedure and endovascular exclusion of the descending thoracic aortic aneurysm. She was closely followed and 2 years later a computed tomography angiography (CTA) revealed the aneurysmal degeneration of the thoracoabominal aorta and bilateral iliac arteries. The patient underwent a composite reconstruction using multi-visceral branched and bifurcated Dacron grafts. At 5 years from her last surgery, a CTA revealed no new dissection or further aneurysmal degenerations. Aortic disease in Marfan patients is a complex clinical problem that may lead to secondary or tertiary aortic reconstructions; close follow-up is mandatory.

A Case of Ascending Aorta Replacement for Chronic Aortic Dissection by Minimally Invasive Cardiac Surgery / 日本心臓血管外科学会雑誌

The number of surgical treatments for acute aortic dissection in octogenarians is increasing. They should return to their daily life as soon as possible after the operation without any complications. Some literature reported that minimally invasive cardiac surgery (MICS) helps quick recovery for the patients. We report a case of minimally invasive ascending aorta replacement for Stanford type A chronic thrombosed aortic dissection in an octogenarian to help quick recovery. An 81-year-old man was admitted in our hospital suffering from chest and back pain. Enhanced CT scan showed Stanford type A acute thrombosed aortic dissection. The diameter of ascending aorta was 45 mm and the diameter of false lumen was 7 mm. Therefore we decided on medical treatment for this patient according to the guideline. After four weeks medical treatment, ascending aorta was dilated to 49 mm and the false lumen also expanded to 9 mm. He underwent minimally invasive ascending aorta replacement to help quick recovery considering his age. He was discharged 11 days postoperatively without any complications. MICS offers a better cosmetic result, less blood loss, less pain, better respiratory function and quick recovery. Thus, minimally invasive operation for the elderly is also very satisfactory.

A Chronic Aortic Dissection with Aberrant Right Subclavian Artery and Kommerell's Diverticulum / 日本心臓血管外科学会雑誌

A 65-year-old woman suffered from left-side paralysis and dysarthria after sudden chest pain, and we diagnosed cerebral infarction caused by type A acute aortic dissection in the Stanford classification. At that time, the aberrant right subclavian artery with Kommerell's diverticulum was found on enhanced computed tomography. The acute aortic dissection with closed false lumen was treated conservatively. Because the ulcer-like projection (ULP) expanded during the course, we performed surgery. Ascending aorta and arch replacement, patch closure of Kommerell's diverticulum and reconstruction of right subclavian artery were performed simultaneously. The postoperative course was good.

Chronic Type B Aortic Dissection Associated with Disseminated Intravascular Coagulopathy : The Risk of a Patent False Lumen in the Chronic Phase / 日本心臓血管外科学会雑誌

Patients with chronic type B aortic dissection usually require surgical repair due to aortic dissection-related complications, whereas those with uncomplicated type B acute aortic dissection can usually be managed with medical therapy. Disseminated intravascular coagulopathy (DIC), as well as aortic enlargement, visceral or limb ischemia and recurrent dissection, has been reported as one of the rare complications of type B aortic dissection which require surgical treatment in the chronic phase. DIC is a severe complication which can result in catastrophic events such as gastrointestinal and cerebral bleeding. The management of DIC as a complication of chronic aortic dissection is still controversial, as medical treatment involving anticoagulants and the supplementation of coagulation factors via a transfusion of fresh frozen plasma is not completely reliable. Surgical treatment to close a false lumen can be corrective, but carries the risk of excessive bleeding due to DIC. We report a patient with chronic type B dissection with a patent false lumen complicated by overt DIC. This patient had frequent occurrences of purpura on the upper and lower extremities. Contrast computed tomography in the late phase showed stagnation of contrast medium in the thoracic false lumen, which strongly idicated this false lumen to be the origin of the DIC. We gave the patient a continuous drip infusion of heparin (12,000 U/day) for 1 week before the operation, after which we performed total aortic replacement in order to thrombose the false lumen. His coagulation profile, including platelet count, prothrombin time, international normalized ratio and clinical symptoms improved immediately after the operation. Computed tomography (CT) performed 3 months after the operation showed complete thrombosis and obstruction of the false lumen in the thoracic aorta. The patient is currently well and has resumed routine activities. The continuous infusion of heparin for 1 week was highly effective to improve the coagulopathy in the present case. This case underscores the importance of conducting follow-up to evaluate coagulation-fibrinolysis system function and to measure the aortic diameter by CT in patients with chronic type B aortic dissection with a patent false lumen. Comparison of the early and late phases of contrast-enhanced CT was extremely useful to determine the cause of coagulopathy in this case. Furthermore, the coagulopathy was successfully treated by total aortic arch replacement to close the entry of the false lumen.

A Case of Widespread Stanford Type A Chronic Aortic Dissection Treated with Arch Replacement Using Transapical Aortic Cannulation, the Arch-First Technique, and Anastomosis of Both Lumens / 日本心臓血管外科学会雑誌

The patient was a 61-year-old woman. In April 2005, she suffered a cerebral infarction and became paralyzed on the right side. In June 2005, a stent graft was placed to treat significant stenosis of the right coronary artery. Computed tomography (CT) in October 2006 revealed widespread patent aortic dissection in both the true and false lumens, extending from the origin of the ascending aorta to the three arch branches and both femoral arteries. Preoperative coronary angiography also showed occlusion of the left anterior descending branch. As a result of these findings, widespread Stanford type A chronic aortic dissection with coronary artery disease was diagnosed, and surgery was performed in February 2007. Brachiocephalic artery dissection and severe stenosis of the right subclavian artery were present, and the left common carotid artery and left subclavian artery were also dissected distally. In addition, both the true and false lumens were patent distal to the aortic arch, with the major abdominal branch bifurcating from both lumens and the dissection extending to the femoral artery, requiring cannulation of both lumens. During surgery, extracorporeal circulation was established by means of blood removal from the right atrium, transapical aortic cannulation, and cannulation of both luminens of the left femoral artery, in an effort to prevent malperfusion due to hypothermia. For revascularization, a Y-shaped artificial blood vessel was used to reconstruct the three arch branches first (the arch-first technique), after which an I-shaped artificial blood vessel was used to form anastomoses distally with both lumens, ensuring perfusion to the false lumen. The proximal anastomosis was then formed, and finally, a single coronary artery bypass graft (CABG) branch was performed using a great saphenous vein graft. No postoperative complications were encountered, and CT showed good blood flow through both luminens below the graft and aortic arch. The patient was discharged from hospital and returned home in an anbulatory condition independently 18 days postoperatively. In this case of widespread type A chronic aortic dissection, the cannulation site was selected and the order of reconstruction and methods of anastomosis were carefully chosen to avoid cardiac malperfusion during arch replacement, resulting in a good outcome.