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症例は60歳女性. 突然の胸背部痛で発症した早期閉塞型 Stanford A型大動脈解離と診断され, 保存的治療を行っていた. 発症後約2カ月で再び胸背部痛が出現し, 解離腔の再開通と診断され, elephant trunk を併用した弓部全置換術を行った. 術後のDSAにて, 人工血管末梢吻合部より解離腔へ造影剤の漏出を認め, 1カ月後にステントグラフト内挿術を施行した. 解離腔は血栓化し早期離床が可能であった.

Cerebral ischemia, bleeding, and inadequate myocardial protection are the major concerns in doing aortic arch operation. The trifurcated graft technique as described by Spielvogel and associates was a useful technique in reducing the risk of postoperative neurologic complications. However, the cerebral ischemic time may be still too long in inexperienced hands. We recently encountered 3 patients of acute type A aortic dissection who needed aortic arch replacement. By modifying the procedure of the trifurcated graft technique and using a reversed sleeve graft technique, we greatly reduced the duration of cerebral and myocardial ischemia and made bleeding a minor problem.

ゼラチン被覆 (Gelseal®) 4分枝付き人工血管を用いた弓部大動脈瘤手術を1996年4月より12月までに9例に施行し, その操作性, 手術成績および問題点について検討を行った. ゼロポロシテイーであるこの人工血管は preclotting の必要がないうえ, 分枝作成の煩わしさもなく, 特に緊急手術時など人員および時間の制約のある場合に有用であると思われた. 手術成績は, 死亡例なく, 急性I型大動脈解離の1例に術後に対麻痺を認めたが, 全例軽快退院し, 良好な結果を得た. しかし, 術後1か月で20%程度のグラフト径の拡大を認めており, 今後の厳重な経過観察を要すると思われた. また, 術後2週目にCRPおよび白血球値の再燃を認めた. 同時期に穿刺を要した心嚢液および胸水の貯留を1例ずつにみたが, グラフトとの関連は不明であった.

We report the case of a 28-year-old man who suffered a transection of the mid-transverse aortic arch between the innominate and left common carotid artery with complete avulsion of the left common carotid artery after blunt trauma. This patient underwent successful aortic arch replacement proximal to the left subclavian artery and reimplantation of the innominate and left carotid arteries using profound hypothermic circulatory arrest and selective antegrade cerebral perfusion. A literature review revealed no other previous reports of survival after this type of injury.

The majority of nonpenetrating traumatic injuries to the thoracic aorta are fatal. Survivors of aortic transection tend to have injuries occurring at the isthmus. We report a rare, blunt traumatic complete transection of the mid aortic arch between the innominate and left common carotid arteries diagnosed by multidetector computed tomography of the chest. The repair was approached anteriorly and required aortic arch replacement.

On diagnosis of Stanford type A acute aortic dissection with an aberrant right subclavian artery, emergency operation was performed. Aortic arch replacement was undertaken with additional 'elephant trunk' procedure to cover the entry site and decrease the blood flow through the false lumen. We consider this technique will become one of the effective procedures for acute aortic dissection involving an aberrant right subclavian artery.

doi:10.1016/j.jtcvs.2004.03.018 Postoperative bleeding is a common complication after prolonged cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA). Experience in the off-label use of recombinant factor VIIa (rFVIIa) after cardiac surgery under the condition of DHCA is very limited, but a recent report demonstrated its efficacy in a case of life-threatening bleeding after elective aortic arch repair in a patient without preexisting hemorrhagic diathesis. We report a case of successfully using rFVIIa in the treatment of severe intractable bleeding after emergency ascending and arch replacement for acute type A aortic dissection with prolonged CPB and DHCA in a patient who received antiplatelet drugs.

Aim. The study is aimed at presenting the protocol of intraoperative organ protection, analyzing its effectiveness during aortic arch surgery and evaluating the rate of postoperative complications in this group of patients. Methods. The study included 141 patients. In the first group (n=70) patients underwent aortic arch surgery with hypothermic circulatory arrest (target core temperature 26 °C) and antegrade cerebral perfusion. Patients of the second group (n=71) underwent ascending aortic replacement using cardiopulmonary bypass with moderate hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all the cases. In the first group transcranial Doppler monitoring was also performed. 33 patients in the first group and 34 patients in the second group underwent testing before and after surgery in order to evaluate cognitive function. Patients’ condition was evaluated during the in-hospital period that was about 15.97±20.54 days. Results. In-hospital mortality rate was 4,2 % in the first group and 0% in the second one (p=0.12). Stroke was observed in 1.4 and 0 % of cases respectively. The rate of encephalopathy (as the leading symptom) was 7.1 and 5.6 % in 1st and 2nd groups respectively. Multimodal monitoring enabled to dynamically adjust the flow rate of antegrade cerebral perfusion. As a result, cerebral SctO2 and linear velocity were maintained within the acceptable range.Conclusion. The presented protocol proved to be effective, it allows to perform aortic arch surgery with the same postoperative neurological complications’ rate as after ascending aortic replacement. We recommend performing reconstructive aortic arch surgery by using moderate hypothermic circulatory arrest (26-28 °С) and selective antegrade cerebral perfusion. In this modality, it is important to perform the distal anastomosis quickly and start patient’s rewarming (this will significantly shorten the duration of cardiopulmonary bypass and, as a result, decrease the rate of postoperative complications) and to carry out both precise intraoperative monitoring of the brain condition (by using cerebral oxymetry and transcranial Doppler) and central core temperature.Received 21 June 2016. Accepted 21 October 2016.Funding: The study had no sponsorship.Conflict of interest: The authors declare no conflict of interest.Author contributionsConceptualization and study design: Belov Yu.V., Charchyan E.R., Akselrod B.A.Material acquisition and analysis: Khachatryan Z.R., Oystrakh A.S., Medvedeva L.A., Guskov D.A., Fedulova S.V.Statistical data processing: Khachatryan Z.R., Guskov D.A., Skvortsov A.A.Article writing: Akselrod B.A., Khachatryan Z.R., Skvortsov A.A. Review & editing: Charchyan E.R., Akselrod B.A., Eremenko A.A., Belov Yu.V.

Figure 1: CT images. (A) Preoperative three-dimensional CT image. Dextrocardia was observed preoperatively. The branches of the aortic arch were mirror-image reversed. (B) Postoperative three-dimensional CT image. Reconstructed aorta and branches were also mirror-image reversed. RV: right ventricle; Ao: aorta; BCA: brachiocephalic artery; Rt.SCA: right subclavian artery; Rt.CCA: right common carotid artery.

Spontaneous ductal aneurysm is rare in adults, although it is diagnosed sporadically, even in the elderly. Commonly, patients with a ductal aneurysm undergo an aneurysmectomy followed by patch-plasty through a lateral thoracotomy. However in older patients, more extensive surgery is often required due to more developed atherosclerotic lesions, requiring total arch replacement. Here, we describe the repair of a ductal aneurysm through a hemi-clamshell incision in an elderly patient. This method enabled excellent exposure of the entire aneurysm and, most importantly, adaptability in performing either an aneurysmectomy followed by patch closure, or total aortic arch replacement, dependent on the extent of the atherosclerotic disease once surgically exposed.

Surgical repair for aortic arch aneurysms is associated with considerable mortality and morbidity. Adequate brain protection is essential. Experience of aortic arch repair in six patients using a four-branched arch graft is described. There were two emergency and three reoperations. One patient had ruptured aneurysm. Hypothermic cardiopulmonary bypass (18-22 degrees C) was employed. A four-branched polymer albumin-coated arch graft was used. The fourth branch of the graft was used for secondary arterial cannulation to ensure continuous brain circulation. One hospital death occurred. No permanent neurological event occurred. The four-branched arch graft facilitates fashioning arch branch anastomoses and provides better brain protection.

Purpose In the treatment of extended distal aortic arch aneurysms with open stent grafting, detailed preoperative minute evaluation is essential to determine the optimal operative strategy and reduce the incidence of complications. We describe a three-dimensional replica of a life-sized aortic arch aneurysm model for aiding preoperative assessments. Description Life-sized replicas of an aortic arch aneurysm were made for 4 patients who underwent total aortic arch replacement with open stent-grafting. These replicas were used to determine the curve of the CLATE, a newly developed open stent delivery system (Senko Medical Instrument Mfg, Co, Ltd, Tokyo, Japan), and the depth of the open stent grafting. The replica and the CLATE system were also used to obtain informed consent from the patients. Evaluation Surgeons could simulate the operative procedure precisely. Insertion of the graft was smooth in all patients. Use of the replica made it easier for the patients to understand the form and site of the aneurysm, as well as the operative procedure. Conclusions The combination of the three-dimensional replica and the CLATE system may be useful for both surgeons and patients in the treatment of extended distal aortic arch aneurysms.

The treatment of Kommerell's diverticulum continues to evolve given advances in aortic surgery, cardiopulmonary bypass management, and endovascular techniques. This case report details the repair of a diverticulum of Kommerell in a Jehovah's witness with a right-sided aortic arch and reviews the surgical literature. (J Card Surg 2010;25:333-335)

We have devised a T-graft technique for selected extensive aortic arch replacement under antegrade cerebral perfusion. Under hypothermic circulatory arrest using antegrade cerebral perfusion, one graft was island-anastomosed to the supraaortic arteries. The other graft was anastomosed to the descending aorta. Proximal and distal grafts were then end-to-side anastomosed in a T-shape. During rewarming, the ascending aorta and proximal graft were anastomosed. The surgical field was good in the 6 patients included in this report. No perioperative deaths or serious complications were encountered. This procedure was effective for patients with extensive aortic arch aneurysm and relatively intact orifices of the supraaortic arteries.

In total aortic arch replacement, distal aortic anastomosis is often remarkably difficult because of the deep operative field. Once bleeding from the anastomotic area occurs, it is intractable not only because of technical problems but also decreased coagulability due to deep hypothermia and the fragility of the aortic wall. We describe a simple but reliable strategy for distal anastomosis, which is unique with regard to the approach to the anastomotic area and the anastomotic method.

Near-infrared spectroscopy can be helpful for monitoring the adequacy of cerebral perfusion during cardiovascular surgery. We report changes seen in regional oxygen saturation due to intraoperative thrombosis of the left common carotid artery graft during hybrid aortic arch replacement for traumatic aortic injury.

In the last decade, the surgical therapy for acute type A aortic dissections (AAAD) has been modified by new techniques that have improved the outcome. Continuous efforts have led to safer, more rapid, and more durable operations using new technology and new knowledge concerning the pathophysiology of the disease and the surgical long-term results. Some of these procedures (like the use of glue or other adjuncts to reinforce the aortic stumps) are already established techniques. Others “in progress” (like different modes of cerebral protection, sites of arterial cannulation, aortic valve management, and the extended aortic arch replacement) are still debated. Finally, procedures like the combined treatment of ascending aortic replacement associated with a stent graft positioned in the aortic arch and other endovascular techniques (hybrid procedures) seem to be the vascular surgical options for the future. These procedures appear as adjuncts to conventional surgical interventions but need to be evaluated for indications, feasibility, and long-term results.

A 65-year-old man developed graft infection 3 years after total aortic arch replacement for a chronic dissecting aneurysm. Redo total aortic arch replacement was performed using an extended homograft following 2 days of open drainage of the mediastinum. The patient has been free from a recurrent mediastinitis over the last 3 years.

We performed aortic arch replacement with a circular staple gun (Intraluminal Stapler System, ILS; Ethicon Endo-Surgery Inc, Somerville ,N J), an automatic anastomosis device used in gastrointestinal surgery. The features of the ILS are adjustable stapler height and controlled compressed tissue thickness, allowing uniform staple formation and providing a leak-free anastomosis and good hemostasis. The circular staple gun has been used in gastrointestinal operations since the 1980s, but its early use was controversial. Now that the device has been standardized, this first report of clinical use in aortic aneurysm surgery is pivotal and likely to change practice in cardiovascular surgery. CLINICAL SUMMARY

われわれは, 54歳の男性で突然の胸背部痛にて発症した Stanford A型急性大動脈解離症例に対し, 超低体温, 完全循環停止下に逆行性脳灌流法を併用し弓部置換術を施行した. 逆行性脳灌流中の中心静脈圧は20mmHg, 送血流量は毎分400ml, 最低直腸温は19℃であった. 逆行性脳灌流時間は135分に及んだが術後脳神経学的合併症を認めずに救命しえた. 超低体温下逆行性脳灌流法の安全限界はいまだ明らかではないが, これにより順行性脳循環停止時間を135分まで延長しうる可能性が本症例より示唆された.

We studied the outcome of our modified aortic arch replacement procedure in which the distal end of the graft is anastomosed between the left common carotid artery and the left subclavian artery including the postoperative physical status of the left arm in comparison with the conventional technique. We assessed the surgical outcome of 26 patients who underwent our new technique and 11 patients who underwent the conventional one. Postoperative clinical symptoms and physical status of the left arm were also evaluated. No operative deaths were observed in the new technique group and one operative death was observed in the conventional group (9.1%). No significant differences between the two groups in postoperative clinical symptoms and the physical status of the left arm were observed. Our “distal anastomosis to the proximal level of the left subclavian artery” technique made aortic arch replacement easier and steadier with a satisfactory surgical outcome in comparison with the conventional method. The postoperative clinical symptoms and physical status of the left arm in the new technique group were identical to those in the conventional group.

Grafts with four presewn side branches have proven very useful for total aortic arch replacement worldwide. However, the four side branches often obscure the surgeon’s view of the distal anastomotic site. Thus, we designed a holder for this graft, which sheaths and hides the graft body and branches, allowing the surgeon a better view of the distal anastomosis. By using this device, distal anastomosis can be achieved early and quickly without obstruction of the surgeon’s view, resulting in reduced cardiac ischemic time in aortic arch surgery.

The authors propose a new strategy of normothermic perfusion for replacement of the aortic arch to avoid the complications of profound hypothermic circulatory arrest. Six patients underwent complete replacement of the aortic arch under normothermia using two pumps for the body (one for the brain and the thoracoabdominal aortic branches) and one for the heart. The surgical procedure was performed with no time limit. There were no operative or late deaths. No patients had neurologic deficit and all were rapidly extubated with uneventful postoperative courses. The method preserves autoregulation of cerebral blood flow and maintains body perfusion without high vascular resistances.

We describe the "eaves" technique, a new method for distal anastomosis in aortic arch replacement. The 1-cm wide eaves were created at the site 3 to 4 cm distal to the graft end. The graft was bound with vessel tape from the eaves to the site proximal to the origin of the first branch to make a working space above the eaves and to facilitate graft handling. Then the native descending aorta was sutured to the eaves easily. The eaves enabled a greater surface contact area between the graft and the inner wall of the aorta and reduced bleeding at the anastomosis.