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Background: Clinical characteristics and treatment outcomes of acute type A aortic dissection with D-dimer elevation have not been clarified., Methods and Results: D-dimer was measured preoperatively within 24 hours of symptom onset in 262 patients with acute type A aortic dissection. The median (and interquartile range) admission D-dimer concentration in our total patient group was 26.7 (8.3-85.9) μg/mL. Median (interquartile range) D-dimer concentrations were 5.0 (2.6-18.0) μg/mL for complete false lumen thrombosis (n=33), 60.9 (19.4-160.4) μg/mL for partial thrombosis (n=81), 26.5 (10.0-70.6) μg/mL for a patent false lumen (n=131), and 8.7 (3.2-26.9) μg/mL for ulcerlike projection (n=17) ( P< 0.01). With a D-dimer concentration of ≤8.3 μg/mL representing the lower quartile, we then investigated predictors of a low D-dimer level. Multivariate analysis showed dissection limited to the ascending aorta ( P< 0.01; odds ratio, 9.81) or descending aorta ( P< 0.01; odds ratio, 7.68), a completely thrombosed false lumen ( P< 0.01; odds ratio, 4.02), and absence of brain ischemia ( P= 0.013; odds ratio, 4.74) to be predictors of the lower D-dimer concentration. Compared with patients with a low D-dimer concentration (≤8.3 μg/mL, n=66), patients with a D-dimer concentration >8.3 μg/mL (n=196) had a reduced preoperative platelet count and increased operation time and transfusion volume. In-hospital mortality was elevated in this group (1.5% versus 11.2%; P= 0.031), although 7-year survival did not differ for hospital survivors (lower versus higher, 93.1% versus 79.1%; P =0.21)., Conclusions: D-dimer concentrations are strongly influenced by the extent of dissection and false lumen status. Operative risks are increased in patients with a relatively high D-dimer concentration., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Surgical treatment for distal arch aortic aneurysm is generally invasive, and there is no definitive approach for it. We report 2 cases of men who was admitted for the treatment of aortic aneurysm. First case is a 78-year-old man. Two saccular aneurysm were observed on distal aortic arch and descending aorta by contrast-enhanced computed tomography. Two staged-repair was performed with using the Lupiae vascular graft and thoracic endovascular aortic repair(TEVAR). The postoperative course was uneventful, and he was discharged on day 21 after 1st operation. Second case is a 68-yearold man. Dessecting aneurysm was observed on distal aortic arch and descending aorta 3 months after incidence of type B aortic dissection. Two staged-repair was performed with using the Lupiae vascular graft and TEVAR. However, additional TEVAR was performed for enlargement of descending aorta half a year after 1st operation. Two staged-repair using Lupiae vascular graft and TEVAR was useful for alleviating a burden of a patient and avoiding paraplegia.

Right-sided aortic arch (RAA) is a rare congenital disorder. We describe herein two cases of thoracic aortic aneurysm with a right aortic arch and right-sided descending aorta treated with thoracic endovascular aortic repair (TEVAR). In one case, a 70-year-old man with Edwards type 1 RAA underwent TEVAR using a Relay stent-graft (Bolton Medical, Barcelona, Spain). In another case, a 72-year-old woman with Edwards type 3 RAA underwent TEVAR using a Kawasumi Najuta stent-graft (Kawasumi Laboratories, Inc., Tokyo, Japan) with the "buffalo horn chimney technique", our original method for left subclavian artery flow preservation. The postoperative courses were uneventful. Postoperative computed tomography showed complete exclusion of the aneurysm without endoleakage. Compared to conventional open surgical repair, TEVAR is challenging in patients with a RAA and right-sided descending aorta. However, our results showed that TEVAR might be feasible and a treatment option even in a patient with a RAA and right-sided descending aorta.

A 74-year-old female patient experienced sudden and severe pain in her lower back and both legs. Upon examination, her femoral pulses were weak, and her legs were pale. Computed tomography revealed a 66-mm thoracic aneurysm in the distal arch and type B aortic dissection. Stenosis was present from the terminal aorta to the iliac arteries. The left common iliac artery was occluded at its bifurcation, and both lower limbs were ischemic. We performed bilateral axillary-femoral artery bypass, which improved blood flow to both limbs. The next day, it was apparent that compartment syndrome had developed in the patient's left leg. Rehabilitation therapy was effective for the compartment syndrome, the patient's symptoms resolved, and she was discharged. We later performed two-stage total arch replacement, and the subsequent clinical course has been without incident.

The Penn classification, a risk assessment system for acute type A aortic dissection (AAAD), is based on preoperative ischemic conditions. We investigated whether Penn classes predict outcomes after surgery for AAAD. Three hundred fifty-one patients with DeBakey type I AAAD treated surgically, January 1997 to January 2011, were divided into 4 groups per Penn class: Aa (no ischemia, n = 187), Ab (localized ischemia with branch malperfusion, n = 67), Ac (generalized ischemia with circulatory collapse, n = 46), and Abc (localized and generalized ischemia, n = 51). Early and late outcomes were compared between groups. In-hospital mortality was 3% (6 of 187) for Penn Aa, 6% (4 of 67) for Penn Ab, 17% (8 of 46) for Penn Ac, and 22% (11 of 51) for Penn Abc. Multivariate logistic regression analysis showed Penn classes Ac and Abc, operation time >6 hours, and entry in the descending thoracic aorta to be risk factors for in-hospital mortality. Incidences of neurologic, respiratory, and hepatic complications differed between groups. Five-year cumulative survival was 85% in the Penn Aa group, 74% in the Penn Ab group (p = 0.027 vs Penn Aa), 78% in the Penn Ac group, and 67% in the Penn Abc group (p <0.001 vs Penn Aa). In conclusion, morbidity and mortality are high in patients with generalized ischemia. The Penn classification appears to be a useful risk assessment system for AAAD, predictive of outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We have successfully performed 2 staged hybrid operation for an extended thoracic aortic aneurysm with Komerell diverticulum, which lessened surgical stress of the patient with avoidance of postoperative complications. An 82-year-old man who had been under observation for thoracic aortic aneurysm was admitted to the hospital with continuous chest discomfort. The patient initially underwent graft replacement for an ascending and arch aneurysm by using the elephant trunk technique. Thirty-five days later, he underwent endovascular repair for the residual descending thoracic aneurysm. The postoperative course was uneventful, and postoperative computed tomography (CT) revealed no stent migration and just a little type II endoleak. This 2 staged hybrid approach might be less invasive than the conventional approach, and be a potential therapeutic option for high risk patients with an extended thoracic aortic aneurysm.