Thoracic stent implantation is indicated.

65-year-old male presenting to the emergency department for appearance of cyanotic mottled lesions on the toes of both feet. Personal history: smoking, hypertension and dyslipidemia. Chest X-ray: mediastinal widening. Thoracic-abdominal-pelvic CT angiography: descending thoracic aortic aneurysm 7 cm in diameter, distal to the left subclavian artery and with mural thrombus. Of the following, indicate the correct option:

Statin therapy is indicated to stabilize the thrombus.

Urgent diagnostic aortography is necessary.

At surgery, the aneurysmal segment is replaced by a tubular prosthesis with reimplantation of the supra-aortic trunks.

Endovascular Approach to Severe Acute Type B Aortic Dissection.

Acute aortic dissection (AAD) is an important emergency that should be identified promptly. The classification of AAD follows two different systems: Stanford (which defines lesions as types A, on the ascending aorta, or B, on the descending aorta) and DeBakey, which also accounts for the extension of the aortic dissection. We present a notable case of a 63-year-old male who presented with a history of abrupt abdominal pain radiating to the dorsal region for endovascular treatment. He was oliguric with symmetric pulses in the superior limbs and reduction of pulses in the left lower limbs, with signs of hypoperfusion. Angiotomography evidenced acute abdominal thoracic aortic dissection classified as DeBakey III and Stanford B, extending through the left iliac artery. He was submitted to endovascular correction of the abdominal thoracic aortic dissection, with implantation of two straight Valiant type endoprosthesis (26x200 mm and 38x200 mm), positioned after the emergence of the left subclavian artery and right above the celiac trunk, respectively. There was also implantation of the stent graft Viabahn (5x60 mm) and Assurant stent (7x30 mm) in the left renal artery. After the urgent surgical intervention, the patient has recovered well. He has been checked in outpatient follow-ups for the past three years with preserved renal function (1.5 mg/dl creatinine) and correct positioning of the endoprosthesis (confirmed by CT without contrast). Hypertension and a smoking history are the most important risk factors associated with aortic dissections, and should be considered when evaluating a patient with chest or back pain (typically described as sharp rather than tearing or ripping) in the emergency department. The endovascular approach to descending dissections was introduced in 1999 and has been established as the standard approach to descending dissections of the aorta, because of the excess mortality of the open approach (32% in open surgery and 7% for those managed with endovascular techniques) and low rate of complications. Ten-year survival rates for patients with AAD ranging from 30% to 60% justifies an aggressive follow-up strategy of discharge, with the goal of minimizing aortic wall stress through drugs (such as β blockers) and surveillance to detect progression. Our report shows that an early detection of symptoms coupled with an aggressive and precise endovascular intervention has produced satisfactory clinical, laboratorial and quality-of-life outcomes in an older patient with an extensive type B arterial dissection.

Endovascular Solutions for Thoracic Aortic Aneurysms with Challenging Anatomies.

The suitability of the proximal and distal landing zones remains one of the main limitations to thoracic endovascular aortic repair. The advent of custom-made scalloped stent grafts widened the endovascular options in some challenging anatomies. The authors present three cases of thoracic aortic aneurysm (TAA), with three different hostile anatomies, successfully treated with custom-made scalloped stent grafts. Case1: Male patient, 47 years old, no relevant medical history. Angio-CT revealed a 54mm post- traumatic TAA, extending distally from the origin of the left subclavian artery. Inadequate sealing in Ishimaru zone 2 was evident. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the left common carotid artery. Proper proximal sealing was obtained. Case2: Male patient, 76 years old, diagnosed with a 65mm diameter TAA, involving the origin of the left subclavian artery. Presence of a bovine trunk, and inadequate landing zone distally to it, were noted. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the bovine trunk. Proper sealing in Ishimaru zone 2 was granted. Case3: Male patient, 77 years old, multiple comorbidities. Angio-CT revealed a 59,3mm saccular aneurysm of the distal thoracic descending aorta, extending proximally from the origin of the celiac trunk. Good collateralization was observed after celiac trunk occlusion test. Proper distal seal was obtained by means of selective embolization of the celiac trunk followed by TEVAR with distal scallop to the superior mesenteric artery. All procedures were uneventful, with no reported endoleaks, birdbeaks, migrations or re- interventions. There are no reported complications at 1-year follow-up. Custom-made scalloped thoracic stentgrafts are an accessible, reproducible and safe therapeutic option when dealing with hostile descending thoracic anatomies, and should be considered as a minimally-invasive effective solution in selected cases.

Successful treatment of a ruptured aortic arch aneurysm using a hybrid procedure.

Aortic rupture has a high mortality rate and can be considered a medical emergency. The standard treatment for aortic rupture is surgical repair. An aortic stent graft for a ruptured descending aorta is considered an effective alternative treatment. However, an aortic stent graft is difficult when the aortic aneurysm is in the aortic arch due to supra-aortic vessels. We report on a patient with a ruptured aortic arch aneurysm treated with a hybrid procedure, which involved a carotid to carotid bypass operation and an aortic stent graft. A 71-year-old male patient visited our cardiovascular center suffering from hemoptysis. The chest CT and aortography showed a 9 cm sized aortic arch aneurysm 0.5 cm distal to the left subclavian artery and a hemothorax in the left lung. The patient refused to undergo a full open operation. We performed a carotid to carotid bypass in advance, and two pieces of aortic stent grafts were placed across the left carotid artery and left subclavian artery. The follow up CT showed the aortic stent grafts, no endoleaks and no thrombus in the aortic arch aneurysm. The patient was discharged from the hospital without complication.

Hybrid cardiac surgery

For aneurysms of the thoracic aorta, thoracic endovascular aortic repair (TEVAR) has become a valid alternative to open repair. This method may even be applied to pathologies of the aortic arch and the distal descending aorta. A common complication of EVAR are endoleaks. These may be missed by 2D angiographic evaluation. Rotational angiography, providing CT-like 3D imaging with the angiographic C-arm enables the surgeon to diagnose this complication intraoperatively and correct it right away. An indication that a hybrid technique would be most beneficial and successful is that the patient has had a previous aortic repair. Patients with chronic dissecting aneurysms are not good candidates for the hybrid approach. In the hybrid one-stage procedure the graft can be check immediately after the placement of the stent. In the hybrid two-stage procedure the total operation time is much shorter and decreases postoperative complications, however there is a risk that the aneurysm could

Endovascular aneurysm repair

The endograft acts as an artificial lumen for blood to flow through, protecting the surrounding aneurysm sac. This reduces the pressure in the aneurysm, which itself will usually thrombose and shrink in size over time. Staging such procedures is common, particularly to address aortic branch points near the diseased aortic segment. One example in the treatment of thoracic aortic disease is revascularization of the left common carotid artery and/or the left subclavian artery from the innominate artery or the right common carotid artery to allow treatment of a thoracic aortic aneurysm that encroaches proximally into the aortic arch. These "extra-anatomic bypasses" can be performed without an invasive thoracotomy. Another example in the abdominal aorta is the embolization of the internal iliac artery on one side prior to coverage by an iliac limb device. Continued improvement in stent-graft design, including branched endografts, will reduce but not eliminate multi-stage procedures.

Surgery_Schwartz

a sternotomy approach. Aneu-rysms involving the descending thoracic aorta are evaluated in terms of criteria (described in the following section) for poten-tial endovascular repair; those unsuitable for an endovascular approach are repaired with open techniques through a left thora-cotomy. A CT scan can reveal detailed information about aortic calcification and luminal thrombus. These details are important in preventing embolization during surgical manipulation.Indications for Operation Thoracic aortic aneurysms are repaired to prevent fatal rupture. Therefore, on the basis of clini-cal history studies and other data, practice guidelines for tho-racic aortic disease43,44,62 recommend elective operation in asymptomatic patients when the diameter of an ascending aortic aneurysm is >5.5 cm, when the diameter of a descending thoracic aortic aneurysm is >6.0 cm, or when the rate of dilata-tion is >0.5 cm per year. In patients with heritable disorders such as Marfan and Loeys-Dietz

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.

The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients. Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome. Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Open aortic surgery

Medical uses OAS is used to treat patients with aortic aneurysms greater than 5.5 cm in diameter, to treat aortic rupture of an aneurysm any size, to treat aortic dissections, and to treat acute aortic syndrome. It is used to treat infrarenal aneurysms, as well as juxta- and pararenal aneurysm, thoracic and thoracoabdominal aneurysms, and also non-aneurysmal aortic pathology. Disease of the aorta proximal to the left subclavian artery in the chest lies within the specialty of cardiac surgery, and is treated via procedures such as the valve-sparing aortic root replacement. Prior to the advent of EVAR, OAS was the only surgical treatment available for aortic aneurysms. It is still preferred at some institutions and by some patients as it may be more durable than EVAR and does not require post-operative surveillance CT scans.

Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection.

Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly. Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early.

Forced Complete Femoral Approach for Urgent Thoracoabdominal Aneurysm Repair Using an Inner Branched Endograft.

A successful case of urgent type II thoracoabdominal aneurysm repair with an inner branched endograft conducted entirely through femoral accesses without the bailout possibility to achieve an upper extremity approach for bridging stents delivery is described. A 70-year-old male patient underwent hybrid treatment for a thoracic aortic aneurysm on complicated type B dissection in 2 steps. First, arch debranching with carotid-carotid-subclavian bypass and then ascending aortic replacement with reimplantation of the anonymous trunk plus TEVAR were performed. The scheduled 1-month control computed tomography angiography (CTA) showed a rapid increase of the false lumen thoracoabdominal aneurysm, with axial diameter measuring more than 10 cm. The repair procedure was based on the use, as off-the-shelf graft, of a prosthesis customized for another patient with inner branches for visceral vessels that well suited the characteristics of the case. A steerable guiding sheath was essential to stabilize the system in the selective and sequential cannulation of 2 of the 4 inner branches (for celiac trunk and superior mesenteric artery) and to complete the bridging stents deployment. Procedure was carried out without complications. In an urgent setting, total endovascular correction of a thoracoabdominal aortic aneurysm exclusively through femoral accesses appears to be feasible when the appropriate tools are available.

[Simultaneous operations for both the repair of the aortic arch aneurysm and repeated CABG].

A 73-year-old female complaining of left thoracic pain was referred to our hospital. In 1988, she had the first CABG of the left circumflex coronary artery (CX) and right coronary artery. On admission in April 1994, chest X-ray and CT scan revealed a saccular aortic aneurysm, 5 x 5 cm in size, extending to the distal to the left subclavian artery. Coronary arteriography showed a patency of the CX graft, but 99% stenosis of the proximal left anterior descending branch (LAD) with delayed opacification. After the repeated median sternotomy, cardiac arrest was achieved with the aortic cross clamping and St. Thomas Hospital solution infusion. CABG to the LAD branch using a saphenous vein was accomplished. Following this, the replacement of the aortic aneurysmal lesion with a prosthetic graft was performed under the selective cerebral perfusion with deep hypothermia. Proximal anastomosis of the vein graft was completed during a rewarming period. The operation was performed without complications. Postoperative course was satisfactory except a few minor transient complications such as athelectasis of the left upper lobe and the intra-thoracic hematoma. After one month's hospitalization, she was discharged, and currently (six months postoperative) remains asymptomatic.

Aortic aneurysm

Screening with ultrasound is indicated in those at high risk. Prevention is by decreasing risk factors, such as smoking, and treatment is either by open or endovascular surgery. Aortic aneurysms resulted in about 152,000 deaths worldwide in 2013, up from 100,000 in 1990. Classification Aortic aneurysms are classified by their location on the aorta. An aortic root aneurysm, or aneurysm of the sinus of Valsalva. Thoracic aortic aneurysms are found within the chest; these are further classified as ascending, aortic arch, or descending aneurysms. Abdominal aortic aneurysms, "AAA" or "Triple A", the most common form of aortic aneurysm, involve that segment of the aorta within the abdominal cavity. Thoracoabdominal aortic aneurysms involve both the thoracic and abdominal aorta. Thoracoabdominal aortic aneurysms comprise some or all of the aorta in both the chest and abdomen, and have components of both thoracic and abdominal aortic aneurysms.

Treatment of symptomatic mobile aortic thrombus.

Mobile thoracic or abdominal aortic thrombi are a potential source of embolism to visceral organs or lower limbs. Detection levels of this type of aortic pathology after any embolic event have increased considerably. Nevertheless, therapeutic management of an intraluminal mobile thrombus of the aorta remains controversial. The aim of this study is to describe the treatment modalities for symptomatic mural aortic thrombi based on three cases diagnosed at our institution and to review the literature. During the last decade, several patients with peripheral embolisation were diagnosed with an intraluminal mobile aortic thrombus. Three patients who were treated differently were selected and reviewed. In addition a literature search was performed on PubMed and Medline from their inception to the present for all English language articles using the following keywords: blue toe syndrome, peripheral arterial embolisation, mobile thrombus and aorta. The advantages and drawbacks of medical management, open and endovascular treatment are described. Three particular patients with embolisation due to a floating aortic thrombus were reviewed. The first patient underwent a thoracotomy with replacement of the descending thoracic aorta. Another case was treated successfully by implanting an endovascular stent graft in the descending thoracic aorta. The last patient was treated medically because of the involvement of the visceral vessels. When reviewing the literature, no randomised controlled trials were found but several case reports have described both open and endovascular techniques. No long-term follow up of this rare pathology is available. In the literature there is no consensus how to treat a symptomatic floating aortic thrombus. This report shows that therapeutic strategies are influenced by the localisation of the thrombus, the co-morbidities of the patient and the physician' s preferences. Endovascular treatment in combination with high dose statins has become the preferred treatment method although long-term data are lacking.

[Completion pneumonectomy combined with graft replacement of thoracic aortic aneurysm by simple clamping].

A 59-years-old male patient who had left upper lobe partial resection 30 years ago. He was seen at the family physician because of cough. A chest X-ray was showing an abnormal mass shadow measuring 3 x 4 cm in left lower lobe like honey comb. And squamous cell carcinoma (SCC) was detected in his sputum. He was diagnosed as primary lung cancer and introduced to our department to have operation. Chest CT-scan was showing lung tumor suspected SCC measuring 4.3 x 2.6 cm in segment 8 faced chest wall. At the same time, we detected thoracic aortic aneurysm and subcarinal lymph node, but could not see where the boundary is, so it was hard to distinguish between parietal thrombus with thoracic aortic aneurysm and swelling subcarinal lymph node. We decided it swelling subcarinal lymph node by three-dimensional treated CT-scan. Aortic angiography was showing proximal descending aortic aneurysm measuring diameter was 4.5 cm. Abdominal CT-scan was showing infrarenal abdominal aortic aneurysm measuring diameter was 5.5 cm. He was diagnosed as primary lung cancer (It. S8, SCC) (cT2N2M0, Stage IIIB), thoracic aortic aneurysm, abdominal aortic aneurysm, and idiopathic pulmonary fibrosis, and had completion pneumonectomy (R 2 b) for primary lung cancer and graft replacement with aneurysm dissection for thoracic aortic aneurysm without extracorporeal circulation. In this operation, we could find swelling subcarinal lymph node measuring 5 x 3 cm instead of parietal thrombus with thoracic aortic aneurysm. Pathological examination diagnosed middle differential SCC and no metastasis from dissected lymph node (PT2N0M0, Stage I A).

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

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. 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. 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. 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.

False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report.

Acute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen. The patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism. We experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis.

[Surgical therapy of arterial occlusions. Indication and results of revascularization in 5370 peripheral arteriosclerotic occlusions].

The results of 5370 revascularizations in peripheral arteriosclerotic occlusive diseases are reported. The operative mortality in 532 carotis interna desobliterations with ischaemia stage II was 2.3%. In stage I of 98 prophylactic operations we lost no patient. Instead of the transthoracic reconstruction we now prefer the extrathoracic bypass because of the lower risk involved. The abdominal aortic aneurysm always is an indication for resection because of the danger of rupture. In cases of 100 operated patients with aneurysm we had a mortality rate in the elective stage of 5.3%, in stage of covered rupture of 47.1% and in ruptured aneurysm 85.7%. The complications in vascular reconstruction of the lower extremity are low. The mortality rate after implantation of aortic bifemoral prosthesis is 3.7%, after an unilateral aortic-femoral prosthesis 2.8% and after all operations below the inguinal ligament 1.0%. Also the femoro-tibial occlusions could be revascularized in bypass-technique with a risk of 1.5% and good early results of 90.3%.

[Early type I Endoleak after Endovascular Management of an Aorto-esophageal Fistula].

Presentation of a clinical case of an aorto-esophageal fistula secondary to thoracic aorta pseudoaneurysm, complicated by early type Ia endoleak after endovascular repair. A 64 years old male patient, with a history of arterial hypertension, smoking, alcohol abuse and ischemic heart disease with previous coronary revascularization was observed because of chest pain and abundant hematemesis, with Angio-CT revealing a 77mm pseudoaneurysm of the descending thoracic aorta, close to the left subclavian artery, with mass effect on the esophagus and trachea and signs of fistulization. He was proposed to endovascular repair with sealing in zone 2 of the aortic arch after building a left carotid-subclavian bypass. In the first 24 hours there were two episodes of massive hematemesis, with new Angio-CT revealing a early distal migration of the prosthesis, conditioning a type Ia endoleak. A carotid-carotid right-left bypass with left carotid ligation was performed and a new endoprosthesis was implanted in the origin of the brachycephalic trunk (zone 1). The final angiography showed aneurysm exclusion with permeability of the supra-aortic trunks. Later contrasted esophageal examination and endoscopy revealed an ulcer of the posterior left lateral wall with clot suggestive of fistula, and an esophageal prosthesis was successfully implanted. It held seven days of antibiotic therapy with ceftriaxone and metronidazole with no evidence of mediastinal infection and with aneurysm exclusion in the CT follow-up. The recognized biomechanical and anatomical complexity of the aneurysmatic thoracic aorta represents a considerable challenge to the endovascular treatment of aorto-esophageal fistulas, especially in aneurysmatic sealing of the aortic arch, with significant rates of type Ia and III endoleaks.

Surgery_Schwartz

the continuing evolution of endovascular technology and the skills of individual interventionalists when stating that the patient’s comorbidities, fully informed patient preference, and the local operator’s long-term success rates Brunicardi_Ch23_p0897-p0980.indd 94227/02/19 4:14 PM 943ARTERIAL DISEASECHAPTER 23Figure 23-52. A. Multidetector computed tomography angiography of the aortoiliac artery circulation in a 63-year-old male with buttock claudication. B. Three-dimensional image reconstruction shows intra-arterial calcification of the aorta (large arrow) and right common iliac artery (small arrow). This is consistent with type I aortoiliac occlusive disease.Figure 23-53. Atherosclerotic disease involving the aortoiliac segment can result in microembolization of the lower leg circulation, resulting in trash foot or digital gangrene of toes.must be considered when making treatment decisions for type B and type C lesions.1,115General Treatment ConsiderationsThere is no effective

Free-floating thrombus of the aorta: 3 case reports.

Idiopathic free-floating thrombus (FFT) of the aorta is a rare occurrence, but it can lead to catastrophic consequences. The initial symptoms are typically cerebral or peripheral embolisms. Surgical thrombectomy and thrombolysis are two primary treatments for FFT. Here, we report three cases of patients with idiopathic FFT in the absence of coagulopathy who were treated successfully by surgery with no recurrent thrombi or relapse of symptoms. Case 1 involved a 72-year-old male patient with a pedunculated thrombus in the distal aortic arch. Case 2 involved a 62-year-old female patient with a cylinder thrombus in the aortic arch and left common carotid artery. Case 3 involved a 65-year-old male patient with three pedunculated thrombi in the ascending aorta, aortic arch, and left subclavian artery. None of the patients had clinical signs of coagulopathy. Pedunculated or cylinder thrombi have a greater risk of breaking off, which can produce severe peripheral embolism in contrast with intramural thrombi (73% vs. 12%). Due to the high embolism risk for each patient, conservative medical treatment by heparinization was deemed inappropriate, so each patient underwent emergency surgical thrombus removal. After surgery, each of the three patients was treated with warfarin for secondary prevention of thromboembolism. At 7-month follow-up in outpatient practice, a computed tomography (CT) scan indicated that Patient 1 had no recurrent thrombus, and the patient has been symptom-free for 11 months. At 1-month follow-up in outpatient practice, a CT scan indicated that Patient 2 had no recurrent thrombus, and the patient has been symptom-free for 8 years. At 3-week follow-up in hospital, a CT scan indicated that Patient 3 had no recurrent thrombus, but he failed to follow-up after discharge, so his follow-up status is unknown. For a large pedunculated or cylinder thrombus located in the thoracic aorta, surgical thrombectomy should be performed. And, in surgical thrombectomy, the location of the cannulas and cross-clamp should be selected carefully according to the location of the thrombus. After surgery, anticoagulant is important to prevent recurrent idiopathic thrombi.

Surgery_Schwartz

and planning necessary procedures. Note that patients with a thoracic aortic aneurysm may also have a second, remote aneurysm.2 In such cases, the more threatening lesion usually is addressed first. In many patients, staged operative procedures are necessary for complete repair of extensive aneurysms involving the ascending aorta, transverse arch, and descending thoracic or thoracoabdominal aorta.61 When the descending segment is not disproportionately large (compared with the proximal aorta) and is not causing symptoms, the proximal aortic repair is carried out first. An important benefit of this approach is that it allows treatment of valvular and coronary artery occlusive disease at the first operation.Proximal aneurysms (proximal to the left subclavian artery) usually are addressed via a sternotomy approach. Aneu-rysms involving the descending thoracic aorta are evaluated in terms of criteria (described in the following section) for poten-tial endovascular repair; those unsuitable

Repair of Chronic Aneurysmal Aortic Dissection Using a Stent Graft and an Amplatzer<sup>®</sup> Vascular Plug: A Case Study.

We report a case in which a stent graft and an Amplatzer<sup®</sup vascular plug (AVP) were effective for the treatment of chronic aneurysmal aortic dissection. The patient was a 52-year-old man. At 45 years of age, he developed acute aortic dissection, for which he underwent surgery 4 times with prosthetic graft replacement in the abdominal aorta, descending thoracic, ascending aorta (without neck branch reconstruction), and thoracoabdominal aorta with the reconstruction of the celiac, superior mesenteric, and bilateral renal arteries. At the time of thoracoabdominal aortic surgery, strong adhesion was evident, particularly in the thoracoabdominal area. The adhesion was dissected in a part of the chest, and prosthetic graft replacement was performed the following day. Subsequently, the dissection of the residual distal aortic arch enlarged, and the patient was examined at our hospital. Computed tomography (CT) revealed a small intimal tear at the site of anastomosis distal to the graft in the ascending aorta and a large intimal tear in the descending thoracic aorta with a maximum diameter of 67 mm. Furthermore, open repair by prosthetic graft replacement seemed difficult; therefore, treatment with stent grafting was considered. Because the prosthetic graft in the abdomen was extremely tortuous, stent-graft insertion via the femoral artery seemed to be impossible. The planned treatment involved the placement of a thoracic stent graft using the chimney technique which included reconstruction of the brachiocephalic artery and left common carotid arteries using chimney stent graft and coverage of the left subclavian artery. The thoracic stent graft was planned to be inserted via the abdominal prosthetic graft site because the abdominal prosthetic graft was crooked and was located close to the body surface. However, a small intimal tear distal to the graft in the ascending aorta which had not been revealed by intraoperative aortography was detected by the selective angiography, and closure with an AVP was attempted for this. The site was successfully closed using an AVP with a wire passing through the tear and into the false lumen. Thereafter, the large tear in the descending thoracic aorta was closed using a stent graft. The patient made good postoperative progress without evidence of paraplegia, and complete thrombosis of the false lumen was confirmed by postoperative CT. CT at 1 year after thoracic endovascular aneurysm repair (TEVAR) showed complete thrombosis of false lumen and aneurysm shrinkage.

[Surgical therapy of ruptured aortic aneurysm involving a Shuford type-3 right-sided aortic arch].

A 64-year-old man was admitted to our hospital with a complaint of severe back pain of sudden onset on Nov. 2, 1988. Aortogram and chest-CT demonstrated a ruptured dissecting aortic aneurysm involving a Shuford type-3 right-sided aortic arch. Emergency operation was done under temporary brachio-femoral arterial bypass. The thoracic aorta was transected distal to an aberrant left subclavian artery. The entry which located proximal to the aberrant subclavian artery was closed by two u-stay sutures with pledgets. The transected aorta was closed and reinforced with Sandwich method using Teflon-felt. The false lumen completely disappeared on chest-CT on 36th day postoperatively, and the patient is now doing well, although re-thoracotomy was necessary because of post-operative bleeding. To our knowledge, this is the first case of repair of a ruptured dissecting aortic aneurysm involving a right-sided aortic arch which is reported to be very rare.

Randall B. Griepp

Spielvogel D, Etz CD, Silovitz D, Lansman SL, Griepp RB. Aortic arch replacement with a trifurcated graft. Annals of Thoracic Surgery. 2007 Feb; 83(2): 3791-3795. Etz CD, Halstead JC, Spielvogel D, Shahani R, Lazala R, Homann TM, Weisz DJ, Plestis K, Griepp RB. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Annals of Thoracic Surgery. 2006 November; 82(5): 1670-1677. Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage. Vascular. 2005 January–February; 13(1): 5-10. Hagl C, Strauch JT, Spielvogel D, Galla JD, Lansman SL, Squitieri R, Bodian CA, Griepp RB. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Annals of Thoracic Surgery. 2003 September; 76(3): 698-702.

[Angioplasty of the arteries of the extremities. Early and mid-term results (up to 3 years) in 492 cases].

Results of iliac, femoral and/or iliac artery percutaneous transluminal angioplasty (P.T.A.) in 492 cases are presented, and the latest technical improvements in the procedure reviewed. Short and medium-term results in iliac artery stenoses were excellent (98 and 96% respectively), obstructions in this region not being treated. The advantage of P.T.A. over surgery is the lack of exposure of patients to the risk of circulatory insufficiency. Very good results were obtained in stenosis of the distal femoral artery, the method being much less effective in cases of long thrombosis. The essential indications are all types of stenosis of limb arteries, while contraindications can be summarized as iliac artery obstructions (because of possible severe retroperitoneal hematomas) and massive atheromatous calcifications. Aortic and graft stenoses are particular indications. Complications are mainly hematomas and thromboses, but these can be reduced in incidence by increasing experience of radiologists in the use of P.T.A. and by improved selection of patients. Progress will also depend on improved control of anticoagulant and thrombolytic treatments. The question is raised as to the need to treat early claudication due to femoral artery stenosis following detection by the Doppler effect test. The essential argument in favor of P.T.A. is the simplicity and safety of the method to the compared reconstructive surgery, a method involving too high a risk.

Abdominal aortic aneurysm

Hemodynamics affect the development of AAA, which has a predilection for the infrarenal aorta. The histological structure and mechanical characteristics of the infrarenal aorta differ from those of the thoracic aorta. The diameter decreases from the root to the aortic bifurcation, and the wall of the infrarenal aorta also contains a lesser proportion of elastin. The mechanical tension in the abdominal aortic wall is therefore higher than in the thoracic aortic wall. The elasticity and distensibility also decline with age, which can result in gradual dilatation of the segment. Higher intraluminal pressure in patients with arterial hypertension markedly contributes to the progression of the pathological process. Suitable hemodynamic conditions may be linked to specific intraluminal thrombus (ILT) patterns along the aortic lumen, which in turn may affect AAA's development.

Thoracic aortic aneurysm

Age The diagnosis of thoracic aortic aneurysm usually involves patients in their 60s and 70s. Risk factors Hypertension and cigarette smoking are the most important risk factors, though the importance of genetic factors has been increasingly recognized. Approximately 10 percent of patients may have other family members who have aortic aneurysms. It is also important to note that individuals with a history of aneurysms in other parts of the body have a higher chance of developing a thoracic aortic aneurysm. Diagnosis Thoracic aortic aneurysm is defined as a cross-sectional diameter exceeding the following cutoff: 4.5 cm in the United States 4.0 cm in South Korea A diameter of 3.5 cm is generally considered dilated. However, average values vary with age and size of the reference population, as well as different segments of the aorta. Screening

[Surgical treatment of aneurysms of the abdominal aorta. Consecutive experience for 12 years].

The authors present their experience with abdominal aortic aneurysm during the last 12 years. From 1976 up to now they treated 70 patients with abdominal aortic aneurysms. Sixty-seven patients (96%) were male, while 3 (4%) female. Mean age was 65 years (S.D. +/- 7.97). 82% of the patients were heavy smokers. Sixty-five patients were treated by means of resection and vascular reconstruction. Their associated pathologies were: M.I. or severe heart ischemia 34 (52.3%), diabetes 13 (20%), hypertension 25 (38.4%), T.I.A. 6 (9.2%), renal insufficiency 13 (20%), and respiratory insufficiency 18 (27.6%). Results demonstrated a 12-year patency rate of 91.8%. Five high-risk patients were treated by means of "palliative" treatment. Associated pathologies and risk factors were: smoking 5 (100%), M.I. or severe heart ischemia 5 (100%), diabetes 2 (40%), hypertension 4 (80%), T.I.A. 2 (40%), renal insufficiency 2 (40%), respiratory insufficiency 3 (60%). Treatment consisted in the sac thrombosis by means of Gianturco-Wallace coils into the aneurysm (2 cases) and iliac artery ligation (3 cases). Both techniques allowed acute thrombosis of the aneurysm. Vascular supply to the lower limbs was performed by means of an axillo-bifemoral reconstruction in all cases. Long-term prognosis of these five patients was poor due to their general condition.

[Immediate results of surgical treatment of proximal aortic dissection].

From 1984 to 1997, 112 patients have been operated at the Department of Cardiac Surgery of the Azienda Ospedaliera of Parma for acute dissection of ascending aorta. They were 73 males and 39 females of mean age 59.2 years (range 19-79); in the majority they presented a history of essential hypertension and atherosclerotic disease: the first diagnostic suspicion has been confirmed either by angio-CT scan or by CT scan plus aorthography and, from 1994, with transesophageal color doppler echocardiography that is becoming a valuable and precise tool wich can be used in emergency room. Bentall type composite repair or modified Bentall technique has been possible in 37 patients, while in the remaning 75, surgical aortic repair has been achieved by interposition of a dacron vascular prosthesis. Cardiac procedures that were performed in addition were coronary bypass grafthing, resuspension of the aortic valve, AVR. Total arch replacement with reimplantation of brachiocephalic vessels were performed in 6 patients and partial in 10, when intimal tear extended into the arc. Thirthythree in hospital deaths (29.4%) occurred (15 in S.O. and 18 in UCI). Follow up of the hospital survivors was conducted at a mean postoperative interval of 55 months (range 2 to 149 months with 6 late death related to aortic dissection). Our experience shows an increased incidence hypertension and aortic atherosclerosis, compared with marfan's syndrome as a source of acute aortic dissection in the late years, transesophageal echocardiography is a excellent tool for aortic dissection but it may miss dissection localized in other aortic portion, the need of an individualized and conservative surgical approach tailored to the pathology encountered.

Lesions of the thoracic aorta and its arch branches simulating neoplasm.

Abnormal radiographic densities in the midportion of the chest are most commonly caused by neoplasms, cysts, or inflammatory disease. However, vascular lesions may present an identical x-ray appearance, with no distinguishing clinical history or physical findings. The cardiothoracic surgeon must be aware of this similarity in order to ensure the most appropriate diagnostic and therapeutic approach. In our experience, the most frequent problem in differential diagnosis is a lesion of the thoracic aorta or its arch branches simulating neoplasm. Nine such cases are presented, with pertinent conventional radiographs angiograms, and computed tomographic (CT) scans. These are considered in anatomic sequence: (1) ruptured sinus of Valsalva aneurysm; (2) ascending aortic aneurysm; (3) tortuosity or aneurysm of the innominate and subclavian arteries; (4) transverse arch aneurysm; (5) pseudocoarctation; and (6) descending aortic aneurysm. Such vascular lesions must be considered early in the evaluation of any juxta-aortic chest density, particularly if the patient is hypertensive and has other manifestations of atherosclerosis. Angiography and computed tomography establish the diagnosis in most instances, although both are less reliable when thrombus fills all or part of an aneurysm. If these methods fail to establish a vascular origin, the possibility of neoplasm is pursued. When neither a vascular nor neoplastic origin can be proved, surgical exploration is indicated in the otherwise good-risk patient.

Hybrid treatment of a true thyreocervical trunk aneurysm in a patient with Type B aortic dissection.

We would like to describe a case with a complex aortic disease treated in hybrid fashion. We present an interesting case of a 65-year-old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease percutaneously treated. An acute Type B aortic dissection occurred and treated with the implantation of a stent-graft which occluded the left subclavian artery due to its extension to the aortic arch. This event required a carotid-subclavian artery bypass due to ischemia of the left arm. An aneurysm in the innominate artery also detected, was treated with another stent-graft implantation 3 months later. At 5-year follow-up, an aneurysm of the thyreocervical trunk was found while the stent-graft of the aorta was well-tolerated without endoleak and the carotid-subclavian graft was patent. The aneurysm was asymptomatic but considering the risk of spontaneous rupture of an aneurysm of this size, elective surgery was indicated. Because the aneurysm was very close to the brachiocephalic bifurcation, open surgical repair would require a sternotomy. The right common carotid artery and right subclavian artery were exposed. The thyrocervical trunk, right internal mammary artery and right vertebral artery were occluded by ligations to isolate the aneurysm. An 8-mm Dacron graft was anastomosed end-to-end to the distal part of subclavian artery. We would like through this case, discuss the role of the hybrid cardiovascular surgery to minimize the postoperative complications in complex cardiovascular pathology. We also discuss the international bibliography about the thyreocervical trunk aneurysm and the treatment options.

Adventist HealthCare White Oak Medical Center

CT imaging Angiography Emergent and routine abdominal aortic aneurysm (AAA) stent graft Carotid stenting Arterial embolization Full spectrum of cardiac surgery Bypass Surgery Beating Heart Surgery Aortic Valve Surgery Mitral Valve Surgery Tricuspid Valve Surgery Thoracic Aortic Procedures Atrial Fibrillation (Maze) Surgery Endoscopic Vein Harvesting Cardiac Tumor Registry Full spectrum of vascular surgery Comprehensive electrophysiology service Catheter ablation Pacemaker and defibrillator implants Monitored Cardiac Rehabilitation Cardiac and Vascular Research through the Center for Cardiac and Vascular Research (CCVR) Percutaneous coronary intervention (PCI) Primary PCI- an early life-saving medical procedure for heart attack patients