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The International Registry of Aortic Dissection (IRAD) reported that the incidence of limb ischemia in Stanford type A aortic dissection( TAAD) was 17%. The incidence of lower limb ischemia in Stanford type B aortic dissection( TBAD) ranged from 5.7% to 30.0%, and in-hospital mortality was high in patients with lower limb ischemia complications. The reasons for this are:ischemia of other organs, especially intestinal ischemia, often coexists in patients with lower limb ischemia, resulting in a high incidence of myonephropathic metabolic syndrome (MNMS);thoracic aortic open surgery is often prioritized under the concept of central repair, and prolonged lower limb ischemia time results in compartmentalization due to ischemia-reperfusion injury. The prolonged ischemic time in the lower extremity results in a high rate of compartment syndrome, MNMS, due to ischemia-reperfusion injury. Therefore, appropriate management of these two major complications is an important factor in saving the lives of patients with acute aortic dissection complicated by lower extremity ischemia. Because the possibility of saving a patient's life is improved by prompt diagnosis and treatment, a team approach is required to save lives and save limbs in close collaboration not only with surgeons but also with other departments and multiple professions.

A 51 years-old male with sudden onset of chest and back pain was referred to our hospital from another hospital. Contrast-enhanced computed tomography( CT) revealed the presence of Stanford type A acute aortic dissection with critically narrow true lumen in the ascending aorta. Then, emergency surgery was performed. One umbilical tape tourniquet was placed around the ascending aorta. A vent tube was inserted into the main pulmonary artery. A venous drainage cannula was inserted into the right atrium. In the head-down position, pulmonary artery venting and venous drainage were initiated. As the blood puressure fell down around 40 mmHg, the ascending aorta was incised. A cannula (DLP 24 Fr) was placed in the true lumen and the aorta was snared. Cardiopulmonary bypass was established followed by selective antegrade cardioplegia, and systemic cooling. An entry was found in the ascending aorta, so ascending aorta graft replacement was performed under selective antegrade cerebral perfusion. There were no perioperative complications, and he was discharged home on 24th postoperative day. There is still remain controversies as to the optimal arterial cannulation site for cardiopulmonary bypass in patients with Stanford type A aortic dissection. We think the ascending aorta is most simply, rapidly and reliably available. In this case, direct true lumen cannulation in the ascending aorta was useful.

Only a few cases of primary lung cancer associated with the right aortic arch have been reported. A treatment report of recurrent lung cancer with the right aortic arch is rare. A woman in her late 70s was diagnosed with lung cancer associated with the right aortic arch. A 3.4-cm tumor was detected in the right middle lobe on CT performed before a knee joint surgery. The tumor was diagnosed as lung adenocarcinoma and categorized as cT2aN0M0 with cStage ⅠB. Subsequently, a right middle lobectomy was performed. Histopathological study revealed pT1cN1M0 with pStage ⅡB tumor. Molecular analysis revealed 85% expression of programmed death-ligand 1(PD-L1). One year after surgery, mediastinal lymph nodes recurred with multiple lung metastases. The number of metastatic lymph nodes reduced after pembrolizumab was administered, followed by the disappearance of lung metastasis. The outcome was recorded as a partial response. She has been alive 2 years after surgery.

Objective: We report the results of infectious endocarditis requiring surgical intervention for aortic root abscess., Methods: We performed 63 surgeries for infectious endocarditis from April 2013 to August 2022. Of those series, we further investigated 10 cases (15.9%, eight males, mean age 67 years, range 46~77 years) requiring surgical intervention for aortic root abscess., Result: Five cases were prosthetic valve endocarditis. Aortic valve replacement was performed in all 10 cases. To repair root abscess, we performed one direct closure, seven patch repairs with autologous pericardium, and two Bentall procedures with stented bioprosthetic valve and synthetic graft, following radical and complete debridement. All patients were discharged alive (mean number of postoperative days 44, range 29~70 days), and no recurrence of infection or late death was observed during the follow-up period (mean 51 months, range 5~103 months)., Conclusion: Although aortic root abscess is a gravely dangerous condition and has a high risk of death, we presented excellent surgical outcomes of this life-threatening disease.

A 73-year-old woman presented with sudden chest and back pain. Computed tomography (CT) revealed Stanford type A acute aortic dissection complicated by occlusion of the celiac artery and stenosis of the superior mesenteric artery. Because there was no clear sign of critical abdominal organ ischemia before surgery, central repair was performed first. Then, after cardiopulmonary bypass, laparotomy was performed to check the blood flow in the abdominal organs. Malperfusion of the celiac artery remained. We therefore made an ascending aorta-common hepatic artery bypass using a great saphenous vein graft. Postoperatively, the patient was saved from irreversible abdominal malperfusion, however, her condition was complicated by paraparesis due to spinal cord ischemia. After a long period of rehabilitation, she was transferred to another hospital for rehabilitation. She is currently doing well at 15 months after treatment.

A 73-year-old woman presented with severe dyspnea. Type A acute aortic dissection with cardiac tamponade was suspected by plain computed tomography (CT). She was referred to our hospital with cardiogenic shock. In our hospital, contrast-enhanced CT revealed a ruptured aortic arch aneurysm and cardiac tamponade, which is a rare and potentially fatal clinical crisis. The left pulmonary artery was compressed by a hematoma, and there was no aortic dissection. Emergent aortic arch replacement under moderate hypothermia with selective cerebral perfusion was successfully performed. A saccular aneurysm at the lesser curvature of the aortic arch ruptured into the pericardial cavity. Her postoperative course was uneventful, and she was discharged home on the 39th postoperative day.

Right-sided aortic arch (RAA) is a rare congenital disorder. A 87-year-old man with chest pain was diagnosed with a right-sided aortic arch and Kommerell's diverticulum by computed tomography (CT). The diverticulum had a maximum diameter of 57 mm, and surgical intervention was chosen because of the possibility of rupture and dissection. We performed thoracic endovascular aortic repair( TEVAR) with a commercially available device, consisting of bypass grafting of the supra-aortic branches. The postoperative courses were uneventful. The patient was discharged from the hospital in good clinical condition. Postoperative CT showed complete exclusion of the diverticulum without endoleak and device migration. Debranching TEVAR for Kommerell's diverticulum was safe and effective.

A 78-year-old female patient was introduced to our hospital with chief complaint of massive hemoptysis. She had a history of total arch replacement using a short elephant trunk for acute Stanford type A aortic dissection 3 years before. A contrast-enhanced computed tomography (CT) revealed kinking of the short elephant trunk and distal aortic arch aneurysm which caused aortobronchial fistula. She was treated by emergency thoracic endovascular aortic repair and long-term administration of antibiotics. Three years later, distal aortic arch aneurysm disappeared by CT and there was no recurrence of hemoptysis. This is the aortic aneurysm was considered to be caused by the short elephant trunk.

An aberrant right subclavian artery (ARSCA) is a relatively rare congenital anomaly of the aortic arch branches. A 63-year-old man suffered from dysphagia, and was referred to our hospital. Computed tomography (CT) revealed an aortic aneurysm (Kommerell's diverticulum) and ARSCA which routed behind the esophagus. We performed total arch replacement with the open stent-grafting technique via median sternotomy. ARSCA was anastomosed to 1 branch of the arch graft at the right side of the trachea, which released esophageal compression. Postoperatively dysphagia disappeared and CT scan indicated successful reconstruction of the distal arch and ARSCA. The open stent-grafting technique is considered to be effective for aortic disease with ARSCA.

A 69-year-old man developed sudden-onset chest and back pain and was brought to our hospital. Enhanced computed tomography (CT) revealed acute Stanford type B aortic dissection extending from the distal aortic arch to a 72 mm abdominal aortic aneurysm( AAA). The acute phase was managed by antihypertensive therapy, and the patient was followed up. Twenty days after the onset of aortic dissection, entry closure of aortic dissection by thoracic endovascular aortic repair and abdominal aorta replacement were performed simultaneously. Aorta remodeling was confirmed by postoperative CT, and the patient's postoperative course was uneventful. In the treatment of patients with acute aortic dissection and AAA, surgical intervention timing and strategy must be considered carefully.

We herein present a case of distal aortic arch aneurysm associated with the bovine arch and the isolated left vertebral artery (ILVA). Incorporating 2 fenestrations, we successfully performed an endovascular repair using the commercially available Najuta fenestrated stent graft system. During surgery, the Najuta was deployed in the aorta so as to allow for the proximal fenestration to be aligned with the orifice of the 1 branch of the aortic arch, and the distal fenestration with the orifice of the ILVA and that of left subclavian artery. Postoperatively, the patient's recovery went well without any cerebral complications, and in a subsequent computed tomography (CT), the patency of all aortic arch vessels and absence of endoleaks was confirmed. For cases of distal aortic arch aneurysm associated with arch anomalies, the endovascular treatment using the Najuta system is not only simple but also reliable in preserving blood flow to the brain and upper extremities.

When ascending aortic replacement (AAR) is performed in patients with DeBakey typeⅠ acute aortic dissection( AAD), residual false lumen of the aortic arch after AAR is a risk factor of remote aortic reoperation. We have principally considered entry resection as a surgical policy for AAD, but since 2013, for cases of re-entry in the brachiocephalic artery, reconstruction of the brachiocephalic artery has been added. We verified whether brachiocephalic artery reconstruction contributes to the thrombus closure of the false lumen of the aortic arch after the operation. Of 68 patients who underwent AAR for DeBakey typeⅠ AAD within a 12 year period, 17 had re-entry in the brachiocephalic artery on preoperative computed tomography (CT). Six patients who underwent brachiocephalic artery reconstruction were assigned to group A, and 11 patients who did not were assigned to group B. We compared the 2 groups. Aortic clamp and selective cerebral perfusion times were significantly longer in group A. By postoperative CT, false lumen of the aortic arch was not found in any case (0%) in group A, but was found in 10( 90.9%) of the 11 cases in group B( p=0.0006). The risk of residual false lumen of the aortic arch significantly decreased in group A. In conclusion, in cases where re-entry is found in the brachiocephalic artery, a false lumen often remains in the aortic arch after AAR. However, by reconstructing the dissected brachiocephalic artery, the false lumen of the aortic arch can be obliterated, which contributes to avoidance of reoperation in a chronic phase.

We report a rare case of the endovascular treatment of a ruptured aneurysm of the right vertebral artery with an aberrant right subclavian artery(ARSA). A 60-year-old woman was urgently admitted because of consciousness disturbance. Brain CT showed subarachnoid hemorrhage, and CT angiography showed a right vertebral ruptured aneurysm. Endovascular treatment of the aneurysm was performed via a transfemoral approach. During the endovascular treatment, the right subclavian artery was found to diverge from the descending aorta on the periphery of the left subclavian artery. An ARSA was detected, and the right vertebral artery(VA)originated from the ARSA. The guiding catheter was passed through the right VA via an ARSA, and the aneurysm was completely embolized. The patient was transferred to another hospital on day 44 without any motor weakness. To our knowledge, this is the first case of an ARSA with a ruptured aneurysm in the right VA for which endovascular treatment was successfully performed via the ARSA. In patients with an ARSA or aberrant left subclavian artery, the artery could merge with Kommerell's diverticulum(KD)at its origin and be histologically fragile. Thus, in patients with an ARSA, attention should be paid to catheterization to avoid injuring the KD. CT angiography of the aortic arch might be considered before endovascular treatment.

We report a successful case of infected thoracic aortic aneurysm treated by endovascular repair. An 82-year-old woman, presenting with intermittent back pain and low-grade fever, was transferred with the diagnosis of infected thoracic aortic aneurysm. High inflammatory reaction and a thickened aortic wall around the aneurysm confirmed the diagnosis. We performed infection control first because enhanced computed tomography (CT) scanning revealed aneurysm was a low-density mass, which denied aortic pseudoaneurysm or rupture. After administration of broad-spectrum antibiotics, low-grade fever was relieved and inflammatory reactions were decreased. CT performed on the 11th hospital day showed the low-density mass was decreased in size. However, CT performed on the 35th hospital day revealed penetrating atherosclerotic ulcer( PAU) into the low-density mass, which was consistent with saccular aortic aneurysm. The patient underwent thoracic endovascular aortic repair( TEVAR). Postoperative course was uneventful and she was discharged on 22nd postoperative day. Oral administration of antibiotics was continued for 6 months after discharge. Eight months after TEVAR, CT revealed disappearance of the aneurysm. The patient showed no recurrence of infection at 5 years of follow-up.

Postoperative chylothorax is known as a possible complication after thoracic surgery, but no treatment strategy has been established. We report a case of successful surgical treatment for postoperative chylothorax after redo aortic arch replacement via median sternotomy. A 48-year-old man, who had undergone redo aortic arch replacement for aortic pseudoaneurysm due to prosthetic vascular graft infection, developed postoperative chylothorax. Despite the conservative treatment with fasting and administration of octreotide for 4 days, there was no effect on reduction in drainage. Surgical repair was performed on postoperative day 13. About 3 hours before surgery, milk was administered from the nasogastric tube to make the drainage milky. After median re-sternotomy, a stump of the thoracic duct was clearly identified and exposed in the posterior mediastinum, and the thoracic duct was easily closed by clipping. There was no recurrence of chylothorax and oral intake was re-started on day 2. Early operation might be effective against postoperative chylothorax.

An 83-year-old woman was injured in a traffic accident. Enhanced computed tomography (CT) showed aortic injury on the isthmus, Stanford type A aortic dissection and intracranial hemorrhage. Neurological deficit was not noted. We immediately started to lower the blood pressure, and her hemodynamic status remained stable. Although intracranial bleeding had not worsened on the next day, a false lumen of the aortic arch was newly enhanced on CT. Emergency total arch replacement with frozen elephant trunk was performed under deep hypothermia and selective cerebral perfusion. Intraoperative angiography showed no endoleak at the descending aorta. Postoperative course was uneventful, and the patient was discharged on the 21st postoperative day. This procedure is useful for aortic injury involving the ascending aorta and the arch.

This is a 2-case report of successful aortic repair surgery for the retrosternal giant aortic aneurysm. Our surgical strategy is "deep hypothermia and left ventricular( LV) unloading under cardiopulmonary bypass before approaching to the aortic aneurysm" in case of possible catastrophic bleeding. Case 1, a 64-year-old woman, had a retrosternal pseudoaneurysm (80 mm) at the distal anastomosis of a Dacron graft used to replace the ascending aorta 7 years before. An LV vent tube was cannulated via the right upper pulmonary vein through an inferior T-shaped ministernotomy. Case 2, an 86-year-old woman, had a retrosternal chronic aortic dissecting aneurysm (66 mm). An LV vent cannula was inserted via the LV apex through a left minithoracotomy. Arch replacement and ascending aorta replacement were performed in Case 1 and 2, respectively, without cardiac, neurological, or any other complications. This strategy is safe and useful in a case with complex aortic disease.

A 67-year-old woman encountered a traffic accident and had chest computed tomography(CT) examination. It revealed a 24 mm Kommerell's diverticulum associated with a right-sided aortic arch and a 15 mm saccular aneurysm of an aberrant left subclavian artery. We performed intra-aneurysmal coil embolization for the left subclavian artery aneurysm after a balloon occlusion test of the left subclavian artery. The postoperative course was uneventful.

Spontaneous rupture of the thoracic aorta is a rare disease with a poor prognosis without obvious trauma, aortic aneurysm and aortic dissection. We report 2 cases of successful endovascular aortic repair for spontaneous rupture of the thoracic aorta. Case 1:A 79-year-old man was referred to our hospital complaining of general fatigue. He returned home without any obvious abnormalities in blood tests and computed tomography (CT). The patient was aware of dizziness and fluttering in the early morning the next day, and was transported to the hospital by shock vital. CT showed rupture of descending aorta, so we performed emergent thoracic endovascular aortic repair (TEVAR). Postoperatively, the patient progressed without paraplegia and was transferred to other hospital on the 15th day of hospital for the purpose of rehabilitation. Case 2:A 87-year-old woman was admitted to hospital with suspected pyelonephritis, but his respiratory status was gradually exacerbated. CT showed a rupture of the thoracic aorta at the distal arch. Ten days ago, CT showed no findings suggestive of aneurysm and dissection at the same site of aorta. We performed emergency TEVAR. She was removed from mechanical ventilation on the 4th postoperative day. We are continuing rehabilitation treatment now.

Bronchial artery aneurysm(BAA) is quite rare, but its rupture is often lethal. Once it is found, treatments should be aggressively considered. A 67-year-old woman was diagnosed to have a 26 mm mediastinal BAA on computed tomography (CT) which was performed for screening. CT revealed a very short inflow vessel of the BAA and arteriovenous fistula at the outflow. Considering these features of the aneurysm, endovascular interventions deemed difficult and surgery was carried out. Because of the fragility, the aneurysm was resected together with the descending aorta and the graft replacement was performed under partial extracorporeal circulation. The patient has no untoward event for 1 year postoperatively. Although most recent reports advocate endovascular interventions, we think surgical treatment is a variable option in selected patients. Careful evaluation for each BAA case would be essential to determine the treatment strategy.

Backgrounds: Direct anastomosis such as end-to-end anastomosis or extended aortic arch anastomosis are the most commonly used technique to repair aortic coarctation or interrupted aortic arch. Direct anastomosis of the aorta sometimes results in restenosis and/or bronchial compression. To avoid these complications, we have used the technique of the aortic reconstruction using an 0.6% glutaraldehyde-fixed autologous pericardium., Patients and Methods: The procedure was performed in 6 patients;4 with aortic coarctation and 2 with aortic interruption. Prognosis, aortic diameter, and the aortic shape measurement on 3-dimensional computed tomography( 3D-CT) were examined postoperatively., Results: There were no early or late deaths. There was no case of recurrent aortic arch obstruction and/or bronchial compression, The postoperative A/T ratio was 0.48±0.04 on 3D-CT., Conclusions: Reconstruction of the aortic arch with a 0.6% glutaraldehyde-fixed autologous pericardium in an aortic coarctation and interruption showed excellent early and midterm outcomes. There were no complications such as bronchial compression or recoarctation. We believe that this technique leads to a higher success for reconstructing the arch to a near to normal morphology and avoiding the so-called Gothic arch, which has been reported to be associated with late complications of hypertension.

An 80-year-old male patient with a history of total arch replacement for thoracic aortic aneurysm 5 years before was introduced to our hospital with a chief complaint of chest pain. Tissue plasminogen activator (t-PA) had been administrated because of acute brain infarction. A contrast-enhanced computed tomography (CT) scan demonstrated a large hematoma in the posterior mediastinum extending from the level of distal aortic arch to the descending aorta together with left pleural effusion. On the next day after admission, CT scan revealed that the hematoma became smaller. This is a rare case of a posterior mediastinal hematoma caused by t-PA with a history of total aortic arch replacement.

A 49-year-old man was admitted to our hospital because of intermittent claudication and refractory hypertension 10 years after surgery to Stanford type A acute aortic dissection. He underwent total arch replacement with an elephant trunk of 22 mm in diameter. Transesophageal echocardiography revealed that distal end of the elephant trunk was stenosed. Systolic blood pressure gradient over this portion reached to more than 100 mmHg. Folding of elephant trunk and thrombus formation were considered to be the cause. Thoracic endovascular aortic repair relieved stenosis and intermittent claudication, and enabled better blood pressure control.

We experienced 2 cases with distal stentgraft-induced new entry (distal SINE) after thoracic endovascular aortic repair( TEVAR) for type B aortic dissection and 1 case after total arch replacement and frozen elephant trunk method for type A dissection. We successfully performed additional TEVAR in all cases. If the stent graft is bent at deployment, distal SINE may occur on the great curvature side of the aorta by the spring back force. Therefore, we must pay attention to appropriate device selection, and even when remodeling of the aorta is good, meticulous follow-up is necessary.

Mid-aortic syndrome (MAS) is a very rare disease characterized by stenosis from the distal of the thoracic aorta to the abdominal aorta, in many case it is found as a result of hypertension and the like, and it needs surgical intervention in early childhood to adolescence. Here, we report a case of MAS which recognized prominent left ventricular myocardial hypertrophy from the early stage and needed surgical intervention in the infancy. We selected patch angioplasty using expanded polytetrafluoro ethylene( ePTFE) graft, and after surgery pressure gradient was disappeared.

We report a case of a 75-year-old woman with residual shunt of patent ductus arteriosus after initial surgical repair. She was successfully treated by thoracic aortic stent graft and residual shunt disappeared. Re-surgical repair for residual shunt of patent ductus arteriosus is very invasive and challenging procedure. Also endo-vascular repair using coil or an occluding device can be problematic because of anatomical change due to initial surgical repair. Thoracic aortic stent graft, as a re-intervention procedure for patent ductus arteriosus, is simple, safe, and useful in elderly patients.

Case 1 was that of a 65-year-old woman. Radical esophagectomy was performed after neoadjuvant chemotherapy(NAC) for lower thoracic esophageal cancer. Nineteen months after surgery, local recurrence was indicated on the dorsal side of the descending aorta. After chemoradiotherapy(CRT)and chemotherapy, residual cancer with aortic invasion was diagnosed. Case 2 was that of a 64-year-old man. Radical esophagectomy was performed after NAC for middle thoracic esophageal cancer. Five months after surgery, local recurrence was indicated between the descending aorta and left inferior pulmonary vein. After CRT and chemotherapy, residual cancer with invasion of the aorta and left lung was diagnosed. In both cases, we inserted an aortic stent and safely performed residual cancer resection including the aortic adventitia. In summary, aortic stent insertion enables safe resection of local recurrent tumors in the aorta after radical esophagectomy.

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.

In order to demonstrate the clinical efficacy of prone positioning(PP), we reviewed 2 elderly patients with respiratory failure who underwent thoracic aortic surgery. Case 1:An 80-year-old man with true thoracic aortic aneurysm (TAA) underwent total arch replacement under moderate hypothermia. Two days after surgery, PP was conducted for 3 hours to treat atelectasis and poor oxygenation. His respiratory state and oxygenation subsequently improved and he was weaned from ventilator assistance. Case 2:An 82-year-old woman with early thrombosed acute type A aortic dissection and cardiac tamponade underwent emergency primary repair of the ascending aorta under moderate hypothermia. Six days after surgery, PP was conducted for approximately 3 hours to improve oxygenation. She was weaned from the ventilator 7 days after surgery. The clinical courses of both cases after PP were uneventful. In order to improve the respiratory state of elderly patients after TAA surgery, PP is effective and useful.

A 63-year old woman was admitted to our hospital due to loss of consciousness [Glasgow Coma Scale (GCS) E1V1M4]. Cerebral angiography showed known severe stenosis in the right common carotid artery and acute occlusion of the left common carotid artery. Enhanced computed tomography(CT) revealed Stanford type A acute aortic dissection. We judged an emergency surgery was not indicated for this comatose patient. Neurosurgeons placed stents into the left common and internal carotid arteries. The next day, the patient regained consciousness (GCS E4V2M6), and we performed ascending aorta replacement. There was an intimal tear in the ascending aorta and proximal end of the left carotid artery stent was visible in the aortic arch. Postoperative course was uneventful, and CT revealed successful aortic repair and patent stents in the left carotid artery. She was transferred to a rehabilitation hospital on postoperative day 44. Although stent insertion into carotid arteries in a patient with acute aortic dissection carries some risks such as making a new intimal tear or catheterizing in a false lumen, early cerebral reperfusion may improve prognosis of the patients with acute aortic dissection with cerebral malperfusion.

We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echoguided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography (TEE) showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography (CT) showed good positioning and dilatation of the stentgraft and the perfect reverse remodeling of thoracic aorta.

The method of hybrid arch thoracic endovascular aortic repair (TEVAR) to treat aneurysm with zone 0 landing has changed according to its invasiveness and complications. The real chimney technique allows supra-aortic bypass from ascending aorta without side clamp is the current choice of treatment. The comprehensive strategy to prevent stroke during hybrid arch TEVAR consisting of magnetization-prepared rapid acquisition with gradient-echo for evaluation of the atheromatous change and balloon protection of the left subclavian artery has contributed for the marked reduction of stroke. Our current strategy of hybrid arch TEVAR with zone 0 landing is discussed.

A sixteen-year-old female patient with congenital aortic stenosis underwent Ross procedure. We monitored bilateral regional cerebral saturation of oxygen (rcSO₂) on the forehead at the right and left of the midline. After aortic and bicavel cannulation, cardiopulmonary bypass was instituted. On the mor- row of aortic cross clamping, the rcSO₂ fell from approximately 55% to below 30%. We searched the cause of this phenomenon, and detected that the tip of aortic cannula was inserted to the left subclavian artery. After repositioning, the bilateral rcSO₂ increased to above 65%. We felt keenly that the monitoring of rcSO₂ is useful to recognize corrective adjustment of the cannula ori- entation, and the avoidance of cerebral hypoperfusion during the cardiopulmonary bypass period.

Total arch replacement and ascending aorta and arch replacement are the gold standard treatments for aortic arch aneurysm and are possible treatment strategies for chronic type A dissection, with good outcomes. However, because total arch replacement is alternative invasive, it can be difficult to perform in some patients. The thoracic endovascular aneurysm repair (TEVAR) landing on zone2 is a less invasive and suitable treatment for descending aortic aneurysm. We challenged to treat the more proximal region of aortic arch with TEVAR. The some type of fenestrated TEVAR were usefull technique for high risk patients. We present the various fenestrated TEVAR procedures. Especially, we designed an endovascular total arch repair procedure with use of in situ fenestration and commercially available devices, and we present our initial experience.

To apply endovascular aortic repair for arch or thoracoabdominal pathology, it is essential to reconstruct the branches originating in the treatment area. In cases that a stentgraft has to reach ascending aorta we perform "in situ fenestration with squid capture technique".During the procedure cerebral circulation is maintained by percutaneous cardiopulmonary bypass. After deploying the stentgraft we stab it by a needle while squeezed by snare wire and stick a covered stentgraft eventually. Unlike chimney technique which also can be applied for zone 0 thoracic endovascular aortic therapy( TEVAR),this method has no risk of gutter leak. For now there are no fenestrated nor branched grafts in Japan so that we should perform hybrid TEVAR for throacoabdominal aneurysms if patients' conditions cannot allow graft replacement. In such a case we make bypasses between the common iliac artery( or left leg of bifurcated graft) and visceral arteries using a quadrated graft. All anastomosis can be done in a retroperitoneal single plane. TEVAR shouldn't be performed simultaneously with bypass because unstable hemodynamic increase risk of paraplegia. We have never experienced paraplegia among 50 cases except for 1 case in which TEVAR had to be done urgently under critical hypotension.

We reported a case of a 90-year-old man who underwent abdominoperineal resection of the rectum for advanced rectal cancer. On the 16th postoperative day, he suddenly lost consciousness during an exchange of the colostomy pouches. His heart arrested in a moment, and cardiopulmonary resuscitation was immediately performed, but in vain. The autopsy imaging revealed collapse of the heart and the thoracic aorta, as well as profuse blood-like effusion in the left pleural cavity. We considered that hemorrhagic shock due to spontaneous rupture of the thoracic aorta was the cause of his death.

We repot a case of type A aortic dissection after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. A 70-year-old man underwent TEVAR for type B aortic dissection. Seven months after TEVAR, follow-up computed tomography revealed type A aortic dissection. We urgently performed total arch replacement with open stent graft. Although TEVAR is currently recommended as the 1st-line treatment for complicated type B aortic dissection with malperfusion or dilatation, retrograde type A aortic dissection might occur as a rare but life-threatening complication. Fragility of the aortic wall and disease progression combined with stent grafting-related injury contribute to its occurrence. Open stent graft technique is useful in such a case.

70-year-old male who had a history of Y-shaped graft replacement of abdominal aortic aneurysm was referred to our hospital for surgical intervention of extended thoracic aortic aneurysm. Although 1 debranching thoracic endovascular aortic repair (TEVAR) was initially scheduled, deployment of the main endograft was eventually cancelled due to severely tortuous bilateral rims of Y-shaped graft, and left carotid artery-left subclavian artery bypass followed by the coil embolization to the orifice of left subclavian artery to prepare for the next operation was performed. Single hybrid operation, including total aortic arch replacement along with elephant trunk insertion and TEVAR was performed at 3 months after the initial operation. On the 191th postoperative day, he was readmitted to our hospital due to marked elevation of C-reactive protein and unknown fever, and enhanced computed tomography showed the pneumomediastinum. Also, fistula formation was identified at the middle portion of the esophagus on the esophagogastroduodenoscopy, and the contrast agent leakage to the outside of the esophagus was demonstrated on the esophagography. He was transferred to another hospital at 7th day after readmission under the definitive diagnosis of mediastinitis due to aortoesophageal fistula for surgical of esophagectomy and mediastinum drainage. Currently, he is discharged from the hospital, and returning for follow-up visit for taking a course of antibiotics.

We report a compromised patient with mycotic aneurysm, who was successfully treated by urgent placement of a stent graft. A man in his seventies was admitted to our hospital with relapsing high fever and back pain during chemotherapy for advanced squamous cell carcinoma of the lung. Contrast CT demonstrated a saccular aneurysm of the thoracic aorta and left pleural effusion. Blood cultures were positive for Escherichia coli producing extended spectrum beta-lactamase (ESBL). Therefore, thoracic mycotic aneurysm was diagnosed. Because of rapid growth on consecutive examinations, absolute bed rest was required. Therefore, we performed antibiotic therapy combined with stent graft placement, which achieved complete exclusion of the aneurysm. He was discharged in an ambulatory state, and his quality of life remained good at home until just before death from terminal state of the cancer.

Case 1 involved a 77-year-old man admitted to our hospital after he lost almost all memory of work on the day before. Diffusion-weighted imaging (DWI) revealed spotty hyperintensities in the bilateral hippocampi, which were considered responsible for the amnesia. Transesophageal echocardiography (TEE) showed severe aortic arch atheroma, 6.8 mm in diameter with extension to the branch. Aortogenic embolism to the bilateral hippocampi was diagnosed. Case 2 involved a 66-year-old woman admitted to our hospital because she had lost all memory of the 5 hours she was out. She had transient anterograde amnesia. DWI revealed no ischemic lesions, but magnetic resonance angiography (MRA) revealed branch occlusion of the right posterior cerebral artery. MRA on hospital day 7 revealed partial recanalization. TEE showed aortic arch atheroma of 3.9 mm in diameter with extension to the branch. In both cases, aortogenic embolism to the hippocampus might have been causally related to transient memory disturbance. In patients with acute memory disturbance, the possibility of ischemic stroke should be considered.

A 66-year-old man, presented with hematemesis and hemorrhagic shock, was transported to our institution. Computed tomographic examination suggested a pseudo-aneurysm formed by bleeding from aorto-esophageal fistula( AEF). We planned staged operations. At first, in an emergent operation, graft replacement of descending aorta, was performed under partial cardiopulmonary bypass, by left thoracotomy approach. AEF was 5 mm in diameter, and existed inside of normal-diameter and non-aneurysmal aortic intima. AEF orifice into pseudo-aneurysm was closed with aortic wall and was sutured tightly. Next day, gastrointestinal fiberscopy was performed, and penetrating ulcer was found at lower esophagus.To prevent infective complications, the 2nd operation, subtotal esophagectomy, cervical esophagostomy, gastrostomy and tube ileostomy were performed by right thoracotomy approach. Post- operative course was uneventful. Two months later, 3rd operation, cervical esophago-gastric anastomosis was performed, uneventfully. Two years and four months elapsed, and no evidences of infection and formation of pseudo-aneurysm were observed.

We reported a case of peripheral embolization arising from diffuse thoracoabdominal aortic thrombi with minimal evidence for atherosclerosis or other aortic pathology. After the patient was treated with anticoagulation therapy, surgical removal of peripheral embolus was performed.

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.

Determination of the input function for the (99m)Tc-ethyl cysteinate dimmer brain uptake ratio ((99m)Tc-ECD BUR) method as a non-invasive quantitative measurement of cerebral blood flow measurement is of critical importance in order to improve the accuracy of this method. The input functions were experimentally obtained by setting the regions of interest (ROIs) in the ascending aorta, aortic arch, and descending aorta on the 49 chest RI-angio images. rCBFs by the BUR method with 3 input functions of the 6 cases were compared with those by the (123)I-iodoamphetamine (IMP) continuous arterial blood sampling method in order to determine the best location for the ROI of the input function. The input function of the ascending aorta was higher than those of the aortic arch and the descending aorta. The input functions of the aortic arch and the descending aorta decreased due to the origin of the three branches of the right brachiocephalic artery, left subclavian artery, and left common carotid artery. A good correlation was found in the regional cerebral blood flow (rCBF) values between the (123)I-IMP continuous arterial blood sampling method and the (99m)Tc-ECD BUR method with the input function of the ascending aorta. Therefore, the ascending aorta is the best location for the ROI of the input function for the (99m)Tc-ECD BUR method.

We report a case of acute subdural hematoma which occurred following cerebrospinal fluid (CSF) drainage during thoracic endovascular aortic repair (TEVAR) surgery. A 63-year-old woman was scheduled to receive TEVAR for thoracic-abdominal aneurysm extending from the descending aorta (T10) to 15 mm above the celiac trunk. Before the TEVAR operation, a lumbar cerebrospinal drain was inserted at L4-5. CSF pressure was maintained at 10cmH2O throughout the operation. The surgical procedure was completed uneventfully. At the end of the surgery, the attending anesthesiologist recognized an inequality in the patient's pupil size. Emergency CT scan reviewed left acute subdural hematoma. The patient underwent emergency external decompression surgery. The benefits of CSF drainage for spinal cord protection is well established, and ischemia of Adamkiewicz artery is prevented by careful control of CSF pressure. However, the use of CSF drainage has been associated with the risk of acute subdural hematoma. Careful observation for amount of CSF drainage is necessary during thoracoabdominal aortic aneurysm repair.

We report a case of successful treatment of a ruptured distal aortic arch aneurysm with cardiac tamponade by using selective cerebral perfusion for protecting the brain. A 79-year-old man had sudden onset of severe chest and back pain. Chest computed tomography (CT) suggested an acute aortic dissection. He was immediately transferred to the emergency room of our hospital. Echocardiography performed on admission revealed intrapericardial fluid, and hemodynamic monitoring suggested cardiac tamponade. After pericardiocentesis and removal of 400 ml bloody fluid, his hemodynamic condition became stable. Enhanced chest CT showed ruptured distal aortic arch aneurysm with pericardial and pleural effusion. Emergency patch plasty of the aneurysm under extracorporeal circulation (ECC) was performed, assisted by selective cerebral perfusion and deep hypothermia. The patient's postoperative course was uneventful, except for minor transient respiratory troubles, and he was able return to his usual activity.

A 46-year-old man was referred to our hospital for abdominal pain. Computed tomography (CT) revealed mobile mass in the descending aorta and multiple systemic embolism. Emergent operation was indicated. Under femoral vein to femoral artery bypass, removal of mobile mass was performed. We resected the mass with stem including aortic wall and closed the aortic defect with the pericardial patch. Postoperative course was uneventful. Histopathology of the mass was organized thrombus with inflammatory change.