Surgical Treatment of Kommerell Diverticulum and the Aberrant Subclavian Artery : Four Case Reports / 日本心臓血管外科学会雑誌

<p>We report 4 cases of aortic graft replacement for Kommerell diverticulum (KD) and the aberrant subclavian artery (ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and <i>in-situ </i>reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.</p>

Síndrome de Marfán y aneurisma abdominal en una adolescente embarazada / Marfan syndrome and abdominal aneurysm in a pregnant adolescent

Se describe el caso clínico de una embarazada de 17 años de edad, con diagnóstico de síndrome de Marfán desde la niñez, quien ingresó en el Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" de Santiago de Cuba a las 27 semanas de gestación, con valvulopatía mitral, aneurisma de la aorta abdominal y anemia ligera. Los resultados de la ecografía abdominal informaron que a 48 mm de la arteria mesentérica superior se observaba dilatación de la aorta con flujo de turbulencia en su interior. La paciente fue tratada desde el inicio con atenolol (25 mg diarios) y Betnesol®, para acelerar la madurez pulmonar del feto por el alto riesgo de parto pretérmino. Se le practicó la operación cesárea a las 37,2 semanas, la cual fue exitosa para el binomio madre-feto.

The case report of a 17 years pregnant adolescent, with diagnosis of Marfan syndrome since her childhood who was admitted in "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba, with a 27 weeks pregnancy, and presenting mitral valvulopathy, aneurysm of the abdominal aorta and mild anemia is described. The results of the abdominal echography revealed that at 48 mm of the superior mesenteric artery, dilation of the aorta was observed with turbulence flow inside. The patient was treated since the beginning with athenolol (25 mg daily) and Betnesol®, to accelerate the lung maturity of the fetus due to the high risk of preterm childbirth. Caesarean section was practiced at 37,2 weeks, which was successful for the binomial mother-fetus.

Hoarseness as the sole symptom of an impending thoracic aneurysm rupture?

Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.

Síndromes aórticos agudos / Acute aortic syndromes

La disección aórtica clásica es el síndrome aórtico más habitual. El común denominador de los síndromes aórticos agudos es la disrupción de la capa media, la presencia de hemorragia dentro de la pared (hematoma intramural), la separación extensa y progresiva de las capas en forma longitudinal (disección aórtica) y la disrupción de la pared debido a una placa ateromatosa que se ulcera (úlcera aterosclerótica penetrante). Los factores de riesgo asociados con mayor frecuencia son la hipertensión arterial (72%), la aterosclerosis (31%) y el antecedente de cirugía cardíaca previa. La clasificación de la disección aórtica aguda depende del sitio anatómico donde se encuentra el daño intimal y del segmento aórtico afectado. Las dos clasificaciones más usadas son los sistemas de DeBakey y Standford. El síntoma más común es el dolor torácico. En diferentes algoritmos se han usado la combinación de signos clínicos, herramientas no imaginológicas (electrocardiograma, los biomarcadores y la radiografía de tórax), y técnicas diagnósticas como el ecocardiograma, la tomografía axial computarizada, la aortografía y la resonancia magnética nuclear. Los síndromes aórticos agudos que comprometen la aorta ascendente son emergencias quirúrgicas. Conclusiones: la disección aórtica continúa siendo una enfermedad vascular catastrófica, a pesar del manejo con técnicas quirúrgicas y el advenimiento de nuevas intervenciones endovasculares. La sospecha clínica y la consulta al especialista en cirugía cardiovascular son pilares fundamentales en el abordaje terapéutico temprano de los pacientes afectados por los síndromes aórticos agudos.

Classic aortic dissection is the most common aortic syndrome. The common denominator of acute aortic syndromes is the disruption of the middle layer, the presence of hemorrhage within the aortic wall (intramural hematoma), longitudinal extensive and progressive separation of the layers (aortic dissection) and disruption of the wall due to ulceration of an atheromatous plaque (penetrating atheromatous ulcer). The risk factors most frequently associated with aortic dissection are hypertension (72%), atherosclerosis (31%) and a history of previous cardiac surgery. The classification of acute aortic dissection depends on the anatomical site of the intimal damage and the affected aortic segment. The two most widely used classifications are the DeBakey and Stanford systems. The most common symptom is chest pain. The combination of clinical signs, non-imaginological tools (electrocardiogram, biomarkers and chest radiography), and diagnostic techniques such as echocardiography, computed tomography, aortography and MRI have been used in different algorithms. Acute aortic syndromes that involve the ascending aorta are surgical emergencies. Conclusions: aortic dissection remains a catastrophic vascular disease, despite surgical management techniques and the advent of new endovascular interventions. Clinical suspicion and consultation with a cardiovascular surgeon are cornerstones in the early therapeutic approach for patients affected by acute aortic syndromes.

Percutaneous implantation of thoracic and abdominal aortic prostheses in patients at high surgical risk

Introducción: el aneurisma aórtico es frecuente; su ruptura depende del diámetro. La cirugía es el manejo de elección; como alternativa está el implante intraluminal de stents. Objetivo: analizar el impacto del implante percutáneo de los stents aórticos en pacientes de alto riesgo quirúrgico con seguimiento mínimo de un año. Método: estudio descriptivo llevado a cabo desde diciembre de 2005 hasta marzo de 2010, en el que se incluyeron 125 pacientes con aneurisma de aorta torácica o abdominal, criterio quirúrgico por su diámetro y que además fueron rechazados por cirugía dado su alto riesgo. Los desenlaces fueron: muerte intraoperatoria, por cualquier causa y relacionada con el aneurisma a uno, seis y doce meses. Las complicaciones se definieron como las vasculares ocurridas durante los primeros treinta días. Resultados: el aneurisma abdominal fue más frecuente (70,4%). La mortalidad total a un seguimiento de 25,7 meses fue 14,8%; de este porcentaje 5,2% fallecieron por causas relacionadas con el aneurisma. Un paciente falleció durante la intervención. Se reintervinieron 4,3% por fugas. Hubo mayor mortalidad relacionada con el aneurisma en los torácicos (14,7 vs. 1,2% p=0,003) y tendencia en los de mayor diámetro (6,9 vs. 5,7 cm p=0,210). No hubo relación entre mortalidad y diabetes mellitus, tabaquismo, enfermedad coronaria, hipertensión arterial o dislipidemia. Conclusiones: la mortalidad relacionada con el aneurisma en pacientes intervenidos con stent graft aórtico es baja. Ésta se asoció a la torácica y al mayor diámetro aneurismático. Las complicaciones no significaron un aumento en mortalidad. En conclusión, en pacientes con aneurisma aórtico y alto riesgo quirúrgico rechazados para cirugía abierta, el abordaje percutáneo es un tratamiento seguro y eficaz a un seguimiento a mediano plazo.

Introduction: aortic aneurysm is common; its rupture depends on the diameter. Surgery is the treatment of choice, and intraluminal stent implantation is an alternative. Objective: to analyze the impact of percutaneous implantation of aortic stents in high-risk surgical patients with a minimum of one y ear follow-up. Method: Descriptive study conducted from December 2005 to March 2010 which included 125 patients with thoracic or abdominal aortic aneurysm, meeting surgical criteria by its diameter and that were rejected from surgery due to their high risk. The outcomes were intraoperative death from any cause and aneurysm-related at one, six and twelve months. Complications were defined as vascular occurred during the first thirty days. Results: Abdominal aneurysm was more frequent (70.4%). The overall mortality at 25.7 months follow-up was 14.8%. Of this percentage, 5.2% died from causes related to the aneurysm. One patient died during surgery. 4.3% were reoperated for leaks. There was higher aneurysm-related mortality in the thoracic (14.7 vs. 1.2% p = 0.003) and a trend in those of larger diameter (6.9 vs. 5.7 cm p = 0.210). There was no association between mortality and diabetes mellitus, smoking, heart disease, hypertension or dyslipidemia. Conclusions: aneurysm-related mortality in patients undergoing aortic stent graft is low. Mortality was associated with thoracic aneurysm and to its greater diameter. Complications did not imply an increase in mortality. In conclusion, in patients with aortic aneurysm and high surgical risk rejected for open surgery, percutaneous approach is a safe and effective treatment in a medium-term follow-up.

Early experience of thoracic endovascular aortic repair: a local single hospital experience / 대한외과학회지

PURPOSE: The purpose of this retrospective study was to evaluate the short- to mid-term results of thoracic endovascular aortic repair (TEVAR) in Wonkwang University School of Medicine & Hospital. METHODS: Between February 2009 and May 2011, 8 consecutive patients had undergone endovascular stent-grafting for thoracic aortic diseases. Five patients were treated for traumatic thoracic aortic injuries, two patients were treated for thoracic aneurysms and one patient was treated for a pseudoaneurysm due to penetrating aortic ulcers. Attempted stent-graft deployment was performed electively in 6 patients and emergently in 2. Follow-up was performed at 1-month, 6-month, 1-year, and annually thereafter. RESULTS: Technical success rates were achieved in 87.5% and the 30-day mortality rate was 0%. Mean hospital length of stay after TEVAR was 30 days in traumatic thoracic aortic injuries and 10 days in thoracic aneurismal diseases. Intra-operative Type I endoleak due to migration at deflation was visualized in 1 patient, which was treated by insertion of another stent-graft. During follow-up, a major complication was encountered in one patient who received carotid-subclavian bypass to relieve left arm ischemia. After 5 months he was treated with arch replacement for aortic arch aneurysm with type I endoleak at proximal site after endovascular treatment. The 30-day mortality rate was 0%. However, 1 case of mortality (12.5%) was observed during the follow-up period. CONCLUSION: The short and mid-term results of endovascular repair of thoracic aortic diseases are promising. TEVAR is an effective procedure in the management of thoracic aortic diseases.

Arcos aórticos torácicos agudos y cuellos cortos: es irremediable el endoleak tipo 1 proximal en un implante endoprotésico? / Arcos aórticos torácicos agudos e colos curtos. é irremediável o endoleaks tipo 1 proximal em um implante endoprotésico? / Acute thoracic aortic arches and short neck: it is inevitable the type 1 endoleak in an endoprosthetic implant?

Introducción: La clasificación de los ángulos aórticos (entre el cayado y la aorta descendente) incluye 3 tipos, en donde el 3 (arco gótico) es el más angulado y el que mayores dificultades proporciona para la correcta fijación proximal de una endoprótesis torácica. El objetivo de este trabajo es presentar la experiencia del Instituto Argentino de la Aorta (I.A.A.O.) en este tipo de situaciones utilizando varios recursos terapéuticos. Métodos: Sobre un total de 130 pacientes tratados por diversas patologías torácicas (aneurismas ateroscleróticos, transección aórtica traumática, disección Tipo B, úlceras aórticas, hematomas intramurales, seudoaneurismas post cirugía de coartación aórtica), en 31 pacientes (24%) fue necesaria la utilización de algún recurso para mejorar la fijación proximal, como la oclusión subclavia izquierda, el uso de stents expandibles por balón de refuerzo, y en los últimos 2 años, además, el uso de una endoprótesis especialmente diseñada para estos casos. Resultados: en todos los casos se logró un sellado adecuado a nivel proximal, debiendo en 5 ocasiones(3.84%) recurrir al uso de un stent expandible por balón, de refuerzo proximal, por persistencia de una fuga inferior. Esta combinación de dispositivos se produjo en los pacientes tratados previamente al uso de la endoprótesis especial para cuellos angulados. Discusión: El uso de dispositivos endovasculares para tratamiento de patologías torácicas diversas ha ganado el terreno de manera exponencial, siendo mucho más aceptado su uso que en el territorio abdominal, debido a la morbimortalidad que la patología torácica acarrea. Recursos como refuerzo proximal de la endoprótesis con stents expandibles por balón o la oclusión de la arteria subclavia izquierda, o ambos, han sido utilizados en esta serie para evitar el fenómeno del “pico de pájaro” que lleva al endoleak Tipo 1 y a la posibilidad de la migración distal de la endoprótesis, transformado el implante en una pesadilla difícil de ...

Introdução: A classificação dos ângulos aórticos (entre o cajado e a aorta descendente) inclui 3 tipos, onde o 3º (arco gótico) é o mais angulado e proporcionando maiores dificuldades para a correta fixação proximal de uma endoprótese torácica. O objetivo deste trabalho é apresentar aexperiência do Instituto Argentino da Aorta (I.A.A.O.) neste tipo de situações, utilizando vários recursos terapêuticos. Métodos: Sobre um total de 130 pacientes tratados por diversas patologias torácicas (aneurismas ateroscleróticos, transecção aórtica traumática, disecção tipo B, úlceras aórticas, hematomas intramurais, pseudoaneurismas pós cirurgia de coarctação aórtica), em 31 pacientes (24%), foi necessária a utilização de algum recurso para melhorar a fixação proximal, como a oclusão subclávia esquerda, o uso de stents expansíveis por balão de reforço, e nos últimos 2 anos também, o uso de uma endoprótese especialmente desenhada para estes casos. Resultados: em todos os casos se obteve um fechamento adequado completo a nível proximal, sendo preciso, em 5 ocasiões (3.84%) recorrer ao uso de um stent expansível por balão, de reforço proximal, por persistência de uma fuga inferior. Esta combinação de dispositivos ocorreu nos pacientes tratados previamente ao uso da endoprótese especial para colos angulados. Discussão: O uso de dispositivos endovasculares para o tratamento de patologias torácicas diversas ganhou terreno de forma destacada, sendo o seu uso muito mais aceito do que no território abdominal, devido à morbimortalidade que a patologia torácica acarreta. Recursos como reforço proximal da endoprótese com stents expansíveis por balão ou a oclusão da artéria subclávia esquerda, ou ambos, foram utilizados nesta série para evitar o fenômeno do “sinal do bico”, que leva ao endoleaks tipo 1 e à possibilidade da migração distal da endoprótese, transformando oimplante em um problema difícil de resolver...

Introduction: The classification of the aortc angulations (between transverse aorta and descending aorta) include three different types. The third one (gotic arch) is the most angulated and the worst for a good endoprostheses fixation to avoid a proximal type 1 endoleak because ofthe “bird beak phenomenom” that occurs. Methods: 130 patients were treated in the I.A.A.O. because of various thoracic aortic diseases including atherosclerotic aneurysms, type B dissections, aortic trauma, aortic ulcers, post coarctation surgery false aneurysms, and in 31 (24%) of them we need to use one of the next resources, left subclavian occlusion, bare stent deployment to reinforce the proximal fixation or a new thoracic endoprostheses specially designed for this kind of angles. Results: all patients were successfully treated, but in 5 of them (3.84%) a balloon expandable stent was deployed to strengthen the proximal fixation. This combination was used previously to the availability of the new endoprostheses (TX2 Prof Form). Conclusions: the use of the mentioned resources to improve the proximal landing zone allowed us to successfully treat pathologies that were located near or over the left subclavian artery.

Surgical Treatment of Aortic Aneurysm and Aortic Dissection:A Retrospective Analysis of 122 Cases / 华中科技大学学报（医学）（英德文版）

The study summarizes the clinical experience of surgical treatments of various types of thoracic aneurysm and aortic dissection.Clinical data of 122 patients with thoracic aneurysm and aortic dissection during July 2005 to July 2008 were retrospectively analyzed.The elective operations were performed in 107 patients while emergency surgery was done in 15 cases.Different surgical strategies were employed on the basis of diseased region,including simple ascending aortic replacement (n=3),aortic root replacement (n=43),hemi-arch replacement/total arch replacement + elephant trunk technique (n=32),thoracic/thoracoabdominal aortic replacement (n=8) and endovascular repair (n=36).In this series,there is 4 cases of perioperative death due to massive cerebral hemorrhage (n=1),respiratory failure (n=1) and multiple organ dysfunction syndrome (MODS) (n=2).Three cases developed post-operative massive cerebral infarction and the relatives of the patients abandoned treatment.Instant success rate of endovascular repair was 100%.The intimal rupture was sealed.Blood flow was unobstructed in true lumen and no false lumen was visualized.It was concluded that aggressive surgery should be considered in the patients with thoracic aneurysm and aortic dissection.Surgical procedures should vary with the location and the nature of the lesions.