Thoracoabdominal aortic aneurysm repair: results of conventional open surgery.

OBJECTIVES: The aim of this study is to report our experience in the surgical repair of thoracoabdominal aortic aneurysms (TAAAs) over the last 27 years against the background of evolving surgical techniques. METHODS: We reviewed the prospectively collected data of 571 patients who underwent open TAAA repair between 1981 and 2008. Data were analysed using univariate and multivariate analysis (logistic regression). Pre-, intra- and postoperative risk factors were used to develop risk models for in-hospital mortality, spinal cord deficit and renal failure. Recent published series were used to highlight the different treatment modalities and explore results. RESULTS: Seventy patients (12.3%) died in the hospital, the 30-day mortality was 8.9%, 37 patients (6.5%) required postoperative dialysis and 47 patients (8.3%) developed paraplegia or paraparesis. The incidence of paraplegia in the left heart bypass group was 4.4%. The predictors for hospital mortality were increasing age (odds ratio 1.096 per year, 95% confidence interval (CI): 1.05-1.14) and the need for haemodialysis (odds ratio 10, 95% CI: 4.7-21.1). For postoperative spinal cord deficit, we found three protecting factors: age above 75 years (odds ratio 0.14, 95% CI: 0.19-1.09), the presence of a post-dissection aneurysm (odds ratio 0.4, 95% CI: 0.17-0.94) and the combined use of cerebrospinal fluid drainage and motor-evoked potentials (odds ratio 0.28, 95% CI: 0.14-0.56). The urgency of procedure (odds ratio 4, 95% CI: 1.8-9) and preoperative serum creatinine level (odds ratio 1.007 per micromole per litre, 95% CI: 1.0-1.01) were significant risk factors for renal failure. CONCLUSIONS: Open TAAA repair intrinsically has substantial complications, of which spinal cord ischaemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. An overview of the results of recently published series is given along with an analysis of our data.

Revascularization strategy in patients with severe concurrent severe carotid and coronary artery disease: ''failure to move forward is reason to regress''.

In the absence of randomized trials, the optimal management of patients with concomitant carotid and coronary artery disease remains disputable. The initial studies of combined or staged carotid endarterectomy in these patients were conceived in an attempt to reduce perioperative mortality. Although encouraging results have been reported with combined carotid endarterectomy and cardiac surgery, this combination requires long operative times and remains a surgical challenge. Recent studies have shown that carotid angioplasty and stenting prior to cardiac surgery is a feasible and effective minimal invasive technique. However, the effect of carotid stenting on the incidence of death and stroke after cardiac surgery is indistinct. Carotid stenting followed by cardiac surgery may provide a valuable treatment for patients with combined carotid and cardiac disease. The high rate of freedom from death and stroke during follow-up supports the long-term durability of this strategy. In the present review, we highlight the available data on carotid stenting and cardiac surgery.

Ascending-descending aortic bypass for the treatment of concomitant severe co-arctation, aortic valve disease and hypoplastic aortic arch.

This report describes a one-stage treatment of a 30-year-old patient suffering from severe aortic valve insufficiency, aortic co-arctation, dilatation of the ascending aorta and arcus hypoplasia. The patient underwent aortic valve, ascending aorta and arch replacement through median sternotomy. The aorta was ligated at the level of the co-arctation, which was located in the proximal part of the descending aorta, and an ascending-descending bypass was created using a transhiatic approach. The postoperative course was complicated by a cerebrovascular accident.

[Diagnostic image (307). A man with dysphagia]. / Diagnose in beeld (307). Een man met dysfagie.

A 51-year-old man suffered from longstanding dysphagia due to a large aneurysm of the thoracoabdominal aorta.

[Trachea compression due to a Kommerell diverticulum in a patient with a right-sided aorta]. / Tracheacompressie door divertikel van Kommerell bij een rechtszijdige aorta.

A 64-year-old man who was evaluated for a long history of a discontinuous barking cough with difficulty in coughing up sputum was found to have 90% stenosis of the trachea. Further imaging studies revealed a right-sided descending aorta with an aberrant left subclavian artery arising from a Kommerell diverticulum. This caused the compression of the trachea. The compression was relieved by transposition of the aberrant left subclavian artery to the ascending aorta and replacement of the aneurysmatic part of the aorta by an endoprosthesis.

Surgical treatment of thoracoabdominal aortic aneurysms by simple crossclamping. Risk factors and late results.

Between 1981 and 1987, 88 consecutive patients were operated on for a thoracoabdominal aortic aneurysm by simple crossclamping and a graft inclusion technique (without shunts or heparin). This article presents an analysis of the operative outcome and long-term follow-up. Patient- and operation-related variables are age (mean 64.3 years, range 28 to 82 years), sex (82% men), rupture (20.5%), diabetes (2.3%), renal insufficiency (34.1%), chronic obstructive pulmonary disease (27.3%), previous aortic operation (31.8%), arterial hypertension (66%), postdissection (18.2%) versus degenerative (80.7%) origin, preoperative shock (11.4%), ischemic cerebrovascular (12.5%) or ischemic heart (17%) disease, peripheral vascular disease (14.8%), renal (mean 48 minutes, range 0 to 83 minutes) and lower spinal cord (mean 21 minutes, range 0 to 68 minutes) ischemic time, number of reattached intercostals, blood loss, and extent of the aneurysm (Crawford classification: type I, 16 patients [18.2%]; type II, 21 patients [23.8%]; type III, 29 patients [33%]; and type IV, 22 patients [25%]. Intraoperative mortality is 1.1% (n = 1). Thirty-day mortality is 5.9% (n = 5). Hospital mortality is 11.4% (n = 10): 7% for elective cases and 28% for ruptured aneurysms (p = 0.014). The survival at 2 years is 78% +/- (4.4%) and at 5 years 54% +/- (5.3%). Postoperative spinal cord injury occurred in 12 patients (13.8%) (5 had paraplegia and 7 had paraparesis) and postoperative renal dysfunction necessitating dialysis in 12 patients (14.1%). Risk stratification for hospital death, late death, renal failure, and spinal cord dysfunction was performed by means of multivariate logistic regression and Cox proportional hazard regression as appropriate. The best fitting model to predict hospital death includes preoperative shock (p = 0.02), female sex (p = 0.06), preoperative elevated serum creatinine level (p = 0.06), and preoperative myocardial infarction (p = 0.08). Variables predictive for late death are postoperative dialysis (p = 0.002), age (p = 0.008), and rupture (p = 0.04). The risk factors of postoperative dialysis are age (p = 0.003) and preoperative serum creatinine level (p = 0.04). The risk of postoperative spinal cord dysfunction increases with longer lower spinal cord ischemic time (p = 0.02) and with the presence of preoperative shock (p = 0.06).

Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients.

BACKGROUND: This analysis was performed to evaluate the results of reoperations on the ascending aorta and aortic root. METHODS: All reoperations (n = 134) on the aortic root and ascending aorta performed between February 1981 and April 1998 were retrospectively analyzed. Indications for reintervention were a true or false aneurysm (35%), acute dissection (3.0%), aortic valve stenosis and/or insufficiency (23.1%), prosthetic valve endocarditis (32.8%), and combinations (4.5%). The principal reoperations performed were aortic root replacement (composite graft, freestyle, aortic allograft, or pulmonary autograft) in 116 patients, ascending aortic replacement in 10 patients, and closure of a false aneurysm in 5 patients. Results were analyzed using univariate statistical methods. RESULTS: Hospital mortality was 6.6% (8 patients). Univariate predictors of hospital death were preoperative functional class III or IV (p = 0.02), an interval of less than 6 months between the primary and actual operation (p = 0.02), preoperative creatinine level of more than 200 micromol/L (p = 0.001), acute aortic dissection (p = 0.001), intraoperative technical problems (p = 0.001), and postoperative dialysis (p = 0.001). Freedom from repetitive reoperation was 99% at 1 year and 98% at 5 and 10 years. CONCLUSIONS: Reoperations on the aortic root and ascending aorta can be performed with an early mortality which is very acceptable.

Risk stratification in acute type A dissection: proposition for a new scoring system.

BACKGROUND: The aim of this study was to develop a scoring system for operative mortality of patients with acute type A aortic dissection. METHODS: Between 1974 and 1999, a total of 252 patients were operated on for an acute type A aortic dissection. We reviewed retrospectively preoperative and intraoperative records to conduct an analysis of risk factors associated with surgery. Multivariate analysis was used to predict operative mortality and to provide a preoperative risk profile of each individual patient that could be used for future patients. RESULTS: Operative mortality was 25.0% (n = 63). A logistic regression model with three explanatory variables to predict operative death showed a good fit: the risk factors associated with operative mortality were preoperative cardiopulmonary resuscitation (p = 0.0013, odds ratio = 15.7) and iatrogenic dissection (p = 0.0014, odds ratio = 9.8). Drained pericardial tamponade (p = 0.0386, odds ratio = 0.12) appeared to be a protective factor associated with decreased mortality. CONCLUSIONS: Because existing scoring systems do not fit this pathologic condition, we propose the use of this Antonius Dissection Scoring System, based on the logistic regression model, to predict the chances of operative mortality for each patient before operation. The survival of patients with concomittant pericardial tamponade may benefit from pericardial drainage.

A 23-year experience with composite valve graft replacement of the aortic root.

BACKGROUND: This is a retrospective study of early and long-term results of composite valve graft replacement of the aortic root. METHODS AND RESULTS: Between July 1974 and July 1997, 244 patients underwent aortic root replacement with a composite valve graft. Mean age was 54+/-15 years. The inclusion technique was used in 178 patients (73.0%), the open technique in 65 (26.5%), and the Cabrol II technique in 1 patient (0.5%). Hospital mortality was 7.8% (70% confidence limit, 6.1% to 9.5%). Independent determinants of hospital mortality were preoperative creatinine level more than 150 micromol/L (p = 0.04), prolonged cardiopulmonary bypass time (p = 0.006), intraoperative technical problems (p = 0.048), and year of operation (p = 0.015). Follow-up was 99.6% complete, median 96 months (range, 2 to 256 months). Fifty-seven patients (25.3%; 70% confidence limit, 22.4% to 28.2%) died during follow-up. Cumulative survival at 5, 10, and 20 years was 76%, 62%, and 33%. Independent risk factors for late death were postoperative complications (p = 0.027), technique for coronary reattachment (p = 0.028), and concomitant aortic arch operation (p = 0.01). Twenty patients (8.8%; 70% confidence limit, 7.0% to 10.6%) underwent reoperation on the aortic root. Estimated freedom from reoperation for pseudoaneurysms at 3 years was 96% in the inclusion group and 94% in the open group (p = 0.236). CONCLUSIONS: Aortic root replacement with a composite valve graft can be performed with low hospital mortality and morbidity. Pseudoaneurysms did occur in the inclusion group, but also in the open group.

Cryopreserved aortic allografts for aortic root reconstruction: a single institution's experience.

BACKGROUND: An evaluation of early and long-term results of aortic root replacement with cryopreserved aortic allografts and echocardiographic follow-up of allograft valve function was performed. METHODS: From September 1989 through May 1998, 132 patients aged 17 to 77 years (mean, 50.8 +/- 14.8 years) underwent freestanding aortic root replacement with a cryopreserved aortic allograft. Eighty-six (65.1%) patients had New York Heart Association class III or IV functional status before operation, and 27 (20.5%) patients underwent emergency operation. Fifty-nine (44.7%) patients had undergone previous cardiac operations. The cause of aortic disease was acute endocarditis in 63 (47.7%) patients, healed endocarditis in 15 (11.3%), degenerative in 20 (15.2%), congenital in 20 (15.2%), failed prosthesis in 10 (7.6%) and rheumatic in 4 (3.0%). Follow-up was complete, with a mean of 42 months. RESULTS: There were 12 hospital deaths (9.1%; 70% confidence limits [CL], 6.6% and 11.6%); 9 of them were operated on for active endocarditis (p = 0.062). Multivariate analysis determined age older than 65 years (p = 0.012) and emergency operation (p = 0.009) as independent risk factors for hospital mortality. During follow-up, 6 (5.0%; 70% CL, 3.0% and 7.0%) patients died. Cumulative survival rate for the entire group was 81.8% +/- 5.4% at 8 years. Freedom from reoperation for structural valve failure was 100%, freedom from reoperation for any cause was 96.3% +/- 1.8% at 8 years. Freedom from endocarditis at 8 years was 97.9% +/- 1.4%. Follow-up of allograft valve function showed no or trivial aortic regurgitation in 97% of patients and absence of stenosis of the allograft in 100%. CONCLUSIONS: Aortic root replacement with cryopreserved aortic allografts can be performed with acceptable hospital mortality and long-term results. The durability of cryopreserved aortic allografts is good, and reoperation for structural valve failure is absent at 8 years.

Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta.

BACKGROUND: To determine the factors that influence hospital death and neurologic complications after surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion. METHODS: From May 1989 through April 1997, 106 patients underwent surgery on the thoracic aorta using circulatory arrest and antegrade selective cerebral perfusion. Mean age was 64.0 +/- 11.5 years. Unilateral antegrade cerebral perfusion was used in 37 patients (35%), bihemispheric antegrade cerebral perfusion in 69 patients (65%). Mean antegrade cerebral perfusion time was 50.5 +/- 20.5 minutes. Indication for surgery was atherosclerotic aneurysm in 60 (56.5%) patients, postdissection aneurysm in 26 (24.4%), acute type A dissection in 16 (15.1%), other in 4 (4.0%). RESULTS: Hospital mortality was 8.5% (n = 9; 70% CL: 5.8%-11.2%). Independent predictors of hospital mortality were rethoracotomy (odds ratio 5.7, p = 0.02), postoperative temporary (odds ratio 17.3, p = 0.02) or permanent (odds ratio 7.5, p = 0.03) neurologic dysfunction, postoperative dialysis (odds ratio 9.9, p = 0.008). Bilateral antegrade selective cerebral perfusion had a favorable impact on hospital mortality (odds ratio 0.08, p = 0.007). Temporary neurologic dysfunction occurred in 3.8% of patients (n = 4; 70% CL: 2.0%-5.6%); preoperative hemodynamic instability (odds ratio 14.8, p = 0.05) and perioperative technical problems (odds ratio 22.2, p = 0.033) were independent determinants of temporary neurologic dysfunction. Permanent central neurologic damage occurred in 5.4% of patients (n = 6; 70% CL: 3.2%-7.6%). Preoperative hemodynamic instability (odds ratio 18.9, p = 0.009) and approach through a left thoracotomy (odds ratio 9.4, p = 0.031) were significant predictors of permanent neurologic damage. CONCLUSIONS: Hospital mortality is affected significantly by the choice of technique used for antegrade cerebral perfusion. The incidence of both temporary and permanent postoperative central neurologic damage is influenced by preoperative hemodynamic instability. Duration of cerebral perfusion had no influence on the postoperative neurologic outcome.

Impact of left heart bypass on the results of thoracoabdominal aortic aneurysm repair.

BACKGROUND: This study evaluated the role of left heart bypass on the results of thoracoabdominal aortic aneurysm (TAAA) operations. METHODS: Two hundred fifty-eight patients had surgical repair of a thoracoabdominal aortic aneurysm between 1981 and 1998 using the inlay technique. Simple cross-clamping was used in 47.7% and left heart bypass (atriodistal) in 52.3%. Further surgical technique was identical: liberal intercostal or lumbar artery reimplantation, cerebrospinal fluid drainage (since 1989), administration of a renal cooling solution, permissive mild hypothermia, and no pharmacologic protection. Both univariate and multivariate analysis were used. RESULTS: The hospital mortality rate was 10.1% overall: 14.6% in the cross-clamp group, and 5.9% in the bypass group (p = 0.02). The risk of hospital death increased with aneurysm rupture (odds ratio 5.6) and when the patient needed postoperative dialysis (odds ratio 7.5). The use of left heart bypass had a mild protective effect on hospital death (odds ratio 0.56). The incidence of postoperative renal failure requiring dialysis was 8.3% overall: 10.9% in the cross-clamp group, and 5.9% in the bypass group (p = 0.16). After multivariate analysis, a longer operative procedure (odds ratio 1.01 per minute) and a longer reappearance time of blue dye in the urine (odds ratio 1.05 per minute) increased the risk of dialysis, whereas the use of atriodistal bypass reduced that risk (odds ratio 0.08). Paraplegia or paraparesis occurred in 10.9% of patients overall: 13.2% in the cross-clamp group, and 8.8% in the bypass group (p = 0.27). After logistic regression, rupture increased the risk of paraplegia or paraparesis (odds ratio 3.2) and dissection reduced it (odds ratio 0.23). CONCLUSIONS: The use of atriodistal bypass is beneficial in patients who had thoracoabdominal aortic aneurysm repair. Hospital mortality rates, postoperative dialysis, and paraplegia/paraparesis were reduced.

Aortic root replacement with the pulmonary autograft: an invariably competent aortic valve?

BACKGROUND: Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic regurgitation (AR), and for pulmonary allograft valve stenosis are identified. METHODS: From February 1991 through April 1998, 80 adults (mean age 34.4 years) underwent pulmonary autograft aortic root replacement. Primary diagnosis was AR in 43 (53.7%) patients, aortic stenosis in 13 (16.3%) and mixed disease in 24 (30%) patients. A root reinforcement ring was used in 32 (40%) patients. RESULTS: There was no hospital mortality. Estimated patient survival is 100% at 7 years. A total of 3 patients underwent reoperation: 2 on the autograft for severe AR, 1 for pulmonary allograft stenosis. Freedom from reoperation on the autograft is 96.7 +/- 2.4% at 7 years. Multivariate analysis indicated bicuspid aortic valve disease as an incremental risk factor for AR at discharge (p = 0.036, odds 3.5). Univariate analysis identified operation for pure AR as risk factor for AR during follow-up (p = 0.041). Mild AR or more increased from 2.5% at discharge to 11.3% during follow-up (p = 0.008). Progression of AR was limited by the use of a reinforcement root ring (p = 0.031). Freedom from mild AR or more in patients with and without a reinforcement root ring was 100% and 72.9 +/- 9.3% respectively, at 5 years (p = 0.119). Pulmonary allograft stenosis occurred in 15 (22.5%) patients. Multivariate analysis revealed that large sized pulmonary allografts were less prone to stenosis (p = 0.048, odds 0.13). CONCLUSIONS: Pulmonary autograft root replacement can be performed with few complications. During follow-up, a significant increase in mild AR or more is observed. The use of a reinforcement root ring is effective in preventing progression of AR.

Acute aortic dissection complicating pregnancy.

BACKGROUND: Acute aortic dissection occurring during pregnancy represents a lethal risk to both the mother and fetus. Our purpose was to study the prevalence, treatments, and outcome of this rare problem and to suggest therapeutic guidelines. METHODS: During the past 12 years, 6 pregnant women were admitted with an acute aortic dissection. Four had a type A and 2 had a type B dissection (Stanford classification). RESULTS: Two of the 4 patients with a type A dissection underwent a combined emergency operation consisting of first cesarean section and then ascending aortic repair. Cesarean section was carried out 5 days after the emergency procedure on the aorta in the third patient, and 16 weeks later in the fourth patient. All 4 fetuses were delivered alive. One fetus died 6 days later, but the other 3 are alive and well at long-term follow-up. Of the 2 patients with a type B dissection, 1 was operated on for celiac ischemia; the other was treated medically. In both cases the fetus died in utero. There were no maternal deaths in either group. CONCLUSIONS: Cesarean section with concomitant aortic repair is recommended for pregnant women with a type A dissection, depending on the gestational age. The maternal hemodynamic status will determine the sequence of the two procedures. Medical treatment is advised for patients with a type B dissection, but surgical repair is indicated if complications such as bleeding or malperfusion of major side branches occur.

Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection.

BACKGROUND: The aim of this study was to determine the durability of aortic valve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root. METHODS: From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 +/- 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 +/- 46 months. RESULTS: The operative mortality was 21.5% (n = 26). Actuarial survival was 72% +/- 4%, 64% +/- 5%, and 53% +/- 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% +/- 2% at 1 year, 89% +/- 4% at 5 years, and 69% +/- 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation. CONCLUSIONS: Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.

Within patient variability of lower extremity muscle responses to transcranial electrical stimulation with pulse trains in aortic surgery.

Intraoperative recording of myogenic motor responses evoked by transcranial electrical stimulation is a method of controlling the integrity of the motor pathways during clamping of the aorta. It is important to know the within patient variability of the transcranial motor evoked potential (tcMEP), before changes within the variability range are interpreted as abnormal during the period of aortic cross clamping. Lower limb muscle responses were obtained in 11 patients, following transcranial electrical stimulation with pulse trains, of 4, 6 and 8 pulses. Under the conditions of partial neuromuscular blockade and a stable low dose propofol/fentanyl/nitrous oxide anaesthetic state, this study shows that multipulse transcranial electrical stimulation reliably produces muscle responses of the lower limb in all patients tested with a coefficient of variation (CV) of around 20%. Eight pulses in the stimulation train produce neurophysiological facilitation that exceeds a 4 pulse train in terms of area under the curve (AUC) and response duration. The use of multipulse stimulation rather than double or single pulse stimulation is recommended in order to increase the clinical efficacy of tcMEP monitoring in aortic surgery.

Extended vertical transatrial septal approach for the removal of left atrial myxoma.

OBJECTIVE: Optimal exposure greatly facilitates left atrial myxomectomy and is mandatory for safe and efficacious tumour removal. The purpose of this study was to evaluate one institutions experience, with an alternative to the classical approach, for the removal of left atrial myxoma. METHODS: In an eight-year period, eight patients underwent surgical removal of left atrial myxoma at our institution using the extended vertical transatrial septal approach, slightly modified compared to the original method of Guiraudon and associates, as the septum was initially incised superiorly instead of through the fossa ovalis. RESULTS: One patient with poor left ventricular function died shortly after the surgical procedure because of low cardiac output. Postoperative course of the other patients was uneventful. No rethoracotomy for bleeding was carried out and no permanent arrhythmias were seen. There was one late death at 4.5 months after operation, for which no clear reason was found. Mean follow-up was 55 months (range 1 to 79 months) and revealed six asymptomatic healthy patients. CONCLUSIONS: We feel that the extended vertical transatrial septal approach provides good exposure of left atrial tumours and facilitates complete surgical removal without inherent complications such as tumour cell dissemination or fragmentation.

Spontaneous resolution late after aortic dissection.

A 50-year-old man was operated on for acute type I (DeBakey classification) aortic dissection. The supracoronary ascending aorta was replaced with an interposition graft. Postoperative computed tomography and angiography clearly revealed a double-barrelled aortic arch, left common carotid artery and descending thoracoabdominal aorta with contrast filling of both true and false lumen starting from the distal anastomosis. The same finding was noted at 1 year follow-up with severe compression of the true lumen by the false lumen. At this time, anticoagulation therapy was stopped. One year later, computed tomography showed spontaneous resolution of the dissection in the aortic arch, left common carotid artery and descending aorta over its full length. This was confirmed by angiography. This case reports illustrates that spontaneous resolution of a dissected descending aorta can occur late after surgery from type 1 dissection, but it remains very rare.

Bilateral antegrade selective cerebral perfusion during surgery on the proximal thoracic aorta.

OBJECTIVE: To assess risk factors for hospital death and neurologic outcome after surgery on the proximal thoracic aorta using moderate hypothermic circulatory arrest and bilateral antegrade selective cerebral perfusion. METHODS: From October 1995 through June 1999, 163 patients with a mean age of 63+/-11 years underwent surgery using bilateral antegrade selective cerebral perfusion. Degenerative aneurysms (55%) and acute type A dissection (28%) were the predominant indications for operation. Forty-six (28%) operations were considered as emergency procedure. Twenty-four (15%) procedures were reoperations. RESULTS: Mean ASCP time was 48+/-20 min. Hospital mortality was 8.6% (n=14; 70% confidence limit (CL): 6.4-10.8%). Univariate risk factors for hospital mortality were acute type A dissection (P=0.003), central neurologic damage <24 h before the operation (P=0.000), preoperative hemodynamic instability (P=0.034), and rethoracotomy for any cause (P=0.036). Logistic regression analysis identified central neurologic damage <24 h (P=0.006, odds ratio 14) as an independent risk factor. Temporary neurologic damage occurred in 3.8% (n=6; 70% CL: 2.3-5.3%) of patients. Logistic regression analysis indicated preoperative hemodynamic instability (P=0.003, odds ratio 13) as an independent risk factor. Perioperative permanent central neurologic damage was reported in another 3.8% (n=6; 70% CL: 2.3-5.3%) patients. Acute type A dissection (P=0.018, odds ratio 8) and the non-use of a midline sternotomy (P=0.049, odds ratio 8) were retained as independent risk factors. CONCLUSION: Hospital mortality and perioperative neurologic complications are not significantly influenced by the duration of antegrade selective cerebral perfusion. Overall complication rate is low.

Percutaneous occlusion of the entry to a leaking false aneurysm after ascending aortic replacement for aortic dissection type A facilitating surgical repair.

A leaking false aneurysm occurred after ascending aortic replacement for aortic dissection type A. Percutaneous balloonocclusion of the entry to the false aneurysm facilitated elective surgical repair.