Total Arch Replacement with a 150-mm J-Graft Open Stent Graft for a Syphilitic Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 66-year-old man was under observation as an outpatient for moderate aortic regurgitation and distal aortic arch aneurysm since 2005. He underwent surgery for gradual expansion of the distal aortic arch aneurysm. Preoperative enhanced computed tomography (CT) revealed a fusiform-type aortic aneurysm with a maximum short diameter of 63 mm. The aneurysm extended from the left subclavian artery to the descending aorta, 67 mm ahead. Based on the preoperative CT, a 150-mm open stent graft (OSG) was selected because of an adequate landing zone when inserted from the proximal site of the left subclavian artery. A 33-mm diameter graft was selected with a diameter 10% larger than that of the aorta at the landing zone. Moreover, the preoperative rapid plasma reagin (RPR) test was positive at 5.5 RU, and the fixed Treponema pallidum latex agglutination (TPLA) test was positive at 4,670 TU. He had undergone treatment for syphilis, and we concluded that the patient harbored antibodies after syphilis treatment. In the operating room, median sternotomy was performed. Cardiopulmonary bypass (CPB) was instated with bilateral axillary artery return, and superior vena cave (SVC) -inferior vena cave (IVC) venous drainage was placed. The aortic wall was strongly adherent to the surrounding tissue, similar to that observed in the aortitis syndrome. We performed aortic valve replacement during the systemic cooling. Under hypothermic circulatory arrest at 25°C with selective cerebral perfusion, the aorta was cut between the left common carotid artery and left subclavian artery. From this site, OSG was inserted to the level of the aortic valve. Total arch replacement was performed with a 30-mm bypass graft. Pathological findings indicated infiltration of lymphocytes and plasma cells around the feeding artery in the aortic aneurysm wall, and the aortic media wall showed fibrillation. Based on the intraoperative and postoperative pathologic findings, we diagnosed the patient with syphilitic aortic aneurysm, and started oral administration of amoxicillin 1,500 mg per day for 3 months. He was discharged on the 13th postoperative day without paraplegia, vocal cord paralysis, or other complications. Although syphilitic aortic aneurysm is rarely seen, it must always be considered as one of the causes of aortic aneurysm.

Huge Syphilitic Aneurysm of the Thoracic Aorta Complicated with Airway Obstruction and Superior Vena Cava Syndrome / 日本心臓血管外科学会雑誌

Today, syphilitic aortic aneurysm is rarely diagnosed due to widespread use of penicillin for early syphilis. Large aneurysms can be symptomatic by compressing on adjacent organs. We report a case of a huge syphilitic aneurysm of the thoracic aorta complicated with airway obstruction and superior vena cava syndrome. A 62-year-old man presented with acute severe dyspnea and distention of superficial veins. Contrast-enhanced computed tomography revealed an aneurysm of the ascending aorta extending to the transverse arch the diameter of which was 90 mm. The aneurysm compressed the bilateral main bronchi and superior vena cava. We performed an emergency operation because respiratory failure persisted despite the support of a ventilator. Since the aneurysm eroded the sternum, median sternotomy was performed under hypothermic circulatory arrest. Dissecting the aneurysm was complicated due to dense adhesion. Ascending aorta and partial arch replacement with reconstruction of the brachiocephalic trunk was successfully performed with antegrade cerebral perfusion. Postoperative computed tomography demonstrated that compression of the bilateral main bronchi was released. The result of preoperative syphilitic serologic test was strongly positive, and pathological findings of the aneurysm wall specimen was compatible with syphilitic aneurysm. Following treatment with benzyl penicillin for 14 days, the patient was discharged on the 19th postoperative day without specific complications.

Valve-Sparing Root Replacement for Syphilitic Aortic Arch Aneurysm with Aortic Regurgitation / 日本心臓血管外科学会雑誌

Syphilitic aortic aneurysm became rare after the discovery of penicillin. Syphilitic aortitis involves the ascending aorta and dilates the aortic annulus, causing aortic valve regurgitation. We report a case of syphilitic aortic aneurysm with severe aortic valve regurgitation, which was successfully treated with the replacement of the valve-sparing root and the total arch. A 55-year-old man, admitted earlier to another hospital for colon diverticulum, was found to have an aortic arch aneurysm. Enhanced computed tomography revealed the aneurysm of the ascending aorta to the transverse arch aorta with the maximum short diameter of the aneurysm at 68 mm. He also had a saccular aneurysm in the ascending aorta. Although he had never had a history of syphilis, a routine laboratory test for syphilis was positive. That said, we looked upon this case as a syphilitic aortic aneurysm. In preoperative cardiac echography, the aortic regurgitation was severe with mild valve stenosis and mainly due to dilation of the aortic root. We thought the native valve could be spared and replaced both the valve-sparing root and the total arch. He was discharged on the 11th postoperative day without any complications.