Aneurysm hybrid treatment by simultaneous replacement of ascending aorta and aortic arch and endoluminal stenting of the descending aorta.

BACKGROUND: Resection of the descending thoracic aorta and replacement with a vascular prosthesis is associated with an increased risk of paraplegia, as opposed to endoluminal stenting. We report on the first case in which a thoracic aortic aneurysm was treated in a hybrid approach, combining surgery with the implantation of a new intraluminal stent during 1 procedure. METHODS: A 76-year-old man with long-standing hypertension suffered from acute chest pain. Magnetic resonance imaging (MRI) revealed a complex aortic aneurysm with increased diameters of the ascending aorta (55 mm), the aortic arch (75 mm), and the descending aorta (50 mm). Supracoronary replacement of the ascending aorta with a 30-mm prosthesis was carried out during cardiopulmonary bypass, cardioplegic arrest, and hypothermia (25 degrees C). Surgery and stenting were carried out during circulatory arrest and antegrade cerebral perfusion. Two stents (length: 23 cm and 17 cm) were placed in the descending aorta via the opened aortic arch under X-ray control, covering the left subclavian artery. Then aortic arch replacement was finished by anastomosing the distal end of the aortic prosthesis to the proximal stent's customized proximal end (Polyester cuff, length 25 mm/diameter 36 mm) together with the aortic wall. The brachiocephalic trunk and left carotid artery along with a vein graft to the left subclavian artery were implanted in the prosthesis. RESULTS: Postoperative course was uneventful except for a pericardial effusion. MRI revealed normal dimensions of the thoracic aorta with complete exclusion of the aneurysm and no leakage. CONCLUSION: Simultaneous replacement of ascending aorta and aortic arch with antegrade endoluminal stenting of the descending aorta using a new type of stent were safely and effectively performed in a patient with an aortic aneurysm.

Surgical treatment of interrupted aortic arch with extraanatomical bypass simultaneous to coronary artery bypass grafting and aortic valve replacement.

An interrupted aortic arch accompanied by further surgically reparable cardiac lesions is a rare combination in adult patients. We describe treatment of an interrupted aortic arch, coronary artery bypass grafting (CABG), and aortic valve replacement (AVR) performed simultaneously through median sternotomy in a 64-year-old man. The patient underwent surgery performed using standard cardiopulmonary bypass with cannulation of the ascending aorta and the right atrium, hypothermia (24.6degreesC), and blood cardioplegic arrest. Four aortocoronary vein grafts and pericardial aortic valve replacement were carried out. Finally, the posterior pericardium was opened, and a 16-mm prosthesis was anastomosed to the descending aorta during side clamping using a 4-0 monofilament continuous suture. Optimal placement of the prosthesis was obtained by guiding it to the ascending aorta laterally to the right atrium and passing it between the inferior vena cava and right inferior lung vein. The operation was carried out without complications, and the postoperative course was uneventful. Magnetic resonance imaging showed competent aortic valve prosthesis and highly decreased collateral flow via the internal mammary arteries. Postoperatively both inguinal pulses were present, and the patient was free of angina. In the presence of an interrupted aortic arch, extraanatomical bypass via the posterior pericardium between the ascending and descending aorta can safely be performed at the same time as CABG and AVR through a median sternotomy.