Total Arch Replacement with Open Stent Grafting for Aberrant Right Subclavian Artery in Two Cases / 日本心臓血管外科学会雑誌

We report two cases of total arch replacement with open stent graft for the aberrant right subclavian artery (ARSA). Case 1 was a thoracic artery aneurysm with an ARSA. We thought it would be difficult to perform in-situ reconstruction of ARSA via median sternotomy, so we performed total arch replacement with the open stent-grafting technique. Therefore the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA proximal to the vertebral artery to achieve complete thrombosis of the ARSA. The postoperative course was uneventful. Case 2 was a Stanford type A acute aortic dissection involving an ARSA with the entry located near the ARSA. Total arch replacement was performed using the open stent-grafting technique to close the entry site and origin of the ARSA. Then the right axillary artery was reconstructed by extra-anatomical bypass and coil embolization of the ARSA. The postoperative course was uneventful. The open stent-grafting technique might be an effective alternative management of thoracic aortic disease with ARSA.

Open Stent Grafting for Stanford Type A Acute Aortic Dissection Originating from an Aberrant Right Subclavian Artery / 日本心臓血管外科学会雑誌

<p>An aberrant right subclavian artery (ARSA) is a relatively rare congenital anomaly of arch branches, occurring in 0.5-2.0% of the population. Stanford type A acute aortic dissection involving an ARSA is rare, and is associated with difficult surgical planning in an emergency situation. We report a case of Stanford type A acute aortic dissection originating from an ARSA in a 50-year-old man. He was referred to our hospital with a chief complaint of chest and back pain. Contrast enhanced CT scan revealed type A aortic dissection involving an ARSA, with the entry located near the ARSA. Given the possible difficulty of performing distal anastomosis over the ARSA and ARSA reconstruction, total arch replacement was performed using the open stent-grafting technique. The postoperative course was uneventful, and a CT scan revealed a thrombosed false lumen and ARSA. The false lumen of the aorta next to the stent graft eventually disappeared at 1 year postoperatively. The open stent-grafting technique might be an effective alternative in the management of Stanford type A acute aortic dissection with ARSA.</p>

Distal Perfusion in Open Stent-Grafting / 日本心臓血管外科学会雑誌

<p><b>Objective</b> : We examined the utility of distal perfusion (DP) in open stent grafting (OSG) for the treatment of thoracic aortic aneurysm. <b>Methods</b> : Fifty patients who underwent OSG were categorized into two groups (the Non-DP group and the DP group) based on the presence or absence of distal perfusion in OSG. There was no statistically significant difference between the two groups with regard to patient characteristics. <b>Results</b> : There was no statistically significant difference between the two groups with regard to operation time, but, cardiopulmonary bypass time (178±22 min vs. 193±18 min ; <i>p</i> <0.01) and aortic cross clamp time (84±23 min vs. 106±19 min ; <i>p</i><0.01) were significantly longer in the DP group. Lower-body circulatory arrest time (46±11 min vs. 20±5 min ; <i>p</i><0.001) was significantly longer in the Non-DP group. Postoperative paraplegia and paraparesis occurred in one case each in the Non-DP group, whereas permanent spinal cord ischemia did not occur in the DP group. Postoperative intubation time (72.6±40.1 h vs. 40.1±34.7 h ; <i>p</i><0.05) was significantly longer in the Non-DP group. There were two in-hospital deaths due to stroke and respiratory failure in the Non-DP group, and one in-hospital death due to respiratory failure in the DP group. The postoperative maximum value of BUN (38.5±15.6 mg/dl vs. 30.8±9.8 mg/dl ; <i>p</i><0.05) and s-Cr (1.9±1.0 mg/dl vs. 1.3±0.4 mg/dl ; <i>p</i><0.01) were significantly higher in the Non-DP group. <b>Conclusion</b> : DP in OSG was an effective method for prevention of spinal cord ischemia, and for protection of respiratory and renal function.</p>

A Case of Open Stent Grafting for Thoracic Aortic Aneurysm Combined with Atypical Coarctation and Aortic Regurgitation / 日本心臓血管外科学会雑誌

A 58-year-old woman admitted for further examination of the proximal descending thoracic aortic aneurysm (TAA) combined with atypical coarctation and aortic regurgitation (AR). The chest CT and aortography confirmed these diagnoses, and revealed a pressure gradient of 40mmHg at the descending thoracic aorta with a severe calcification of the aortic wall, and severe AR. We scheduled a one-stage operation for this patient. First, we performed aortic valve replacement. Then we made a graft replacement from the aortic arch to the descending aorta using a stent graft via the aortic arch. Finally we did a reconstruction for lower limb perfusion using an aorto-iliac (extra-anatomical) bypass. The patient is now doing well 3 years after the surgery without any endoleak and without any difference of blood pressure between upper and lower limbs.