Hybrid Approach to Complex Stanford Type B Dissection: Unusual Extra-anatomical Bypass (Aorto-Celiac-Mesenteric Bypass) + Thoracic Endovascular Aortic Repair (TEVAR) + Cholecystectomy

Abstract Patients with complex Stanford type B aortic dissection are very difficult to treat. Many methods have been proposed so far in the treatment of these patients, and the emergence of hybrid techniques has made the treatment easier. In this article, we shared the extra-anatomical bypass (aorto-celiac-mesenteric bypass) + thoracic endovascular aortic repair + cholecystectomy operation technique applied to a patient with complex type B aortic dissection.

Stent-Graft Re-expansion Following Axillo-Bifemoral Bypass : A Case of Stent Graft Collapse due to Acute Type B Aortic Dissection / 日本心臓血管外科学会雑誌

We describe a rare complication and treatment progression that occurred in a 64-year-old man with an aortic abdominal aneurysm (AAA) that had been treated by endovascular aneurysm repair (EVAR). He had undergone EVAR to treat an infra-renal type AAA 21 months previously and returned to the emergency department with back pain. Contrast-enhanced computed tomography (CT) revealed acute type B aortic dissection, so he was admitted and conservative medical management was started. Acute stomachache and limb pain appeared on hospital day 7, which prevented him from moving his lower limbs. The main body of the stent graft had collapsed, blocking blood flow, and contrast was not found in arteries from the collapsed stent graft portion to the knee level on emergency contrast CT images of the leg. His legs were revascularized by an extra-anatomical right axial-bilateral external iliac bypass. His symptoms disappeared and reperfusion injury was avoided. The collapsed stent graft had retained its original shape at 11 and 18 days after surgery. Furthermore, follow-up CT 4.5 years later showed that the stent graft retained its original form.

A Case of Axillofemoral Bypass Graft Stump Syndrome Occurring in Both the Upper and Lower Extremities / 日本心臓血管外科学会雑誌

Acute ischemia due to thromboembolism caused by occluded prosthetic graft after axillary-femoral artery bypass has been reported as axillofemoral bypass graft stump syndrome (AxSS). AxSS usually occurs in the upper extremities and it is rare that it occurs in the lower extremities. We encountered a rare case of a 76-year-old woman with acute right upper and lower extremities ischemia 4 years after right axillary-external iliac artery bypass grafting. The graft and the native arteries of the right upper and lower limbs were occluded. In addition, the right axillary artery and proximal anastomotic site were deformed. We diagnosed acute limb ischemia due to AxSS and immediately performed thrombectomy. Because we considered the thrombosis to originate from the axillary-iliac artery bypass graft, we disconnected the occluded graft from the native arteries. Six months after surgery, she was doing well without recurrence of thromboembolism. We report here the successful treatment of a case of AxSS that developed in both the upper and lower extremities.

Recurrent of Aortic Coarctation in Extra-anatomical Bypass Surgery / 日本心臓血管外科学会雑誌

Recoarctation, systemic hypertension, aortic aneurysm and intracranial aneurysm are generally observed within a certain period after the surgical procedure for aortic coarctation, which is known as a systemic diseases caused by not only morphological abnormalities but also arterial functional abnormalities of artery. Here, we report a case who showed complications of recoarctation, hypertension and subarachnoid hemorrhage after surgery for aortic coarctation. A 17-year-old boy originally presented to our hospital with upper extremity systemic hypertension. Recoarctation after surgery for aortic coarctation was diagnosed in his childhood, following which hypertension was followed while he received continuous treatment with anti-hypertensive drugs. He was hospitalized with sudden headache and loss of consciousness. Since subarachnoid hemorrhage was diagnosed by computed tomography, clipping of intracranial aneurysms was performed. After the clipping procedure, he underwent percutaneous intravascular stenting angioplasty. However, the pressure gradient remained and sufficient dilatation was not obtained because of the hypoplastic anatomical distal aortic arch (from the left internal carotid artery to the site of recoarctation) due to the development of collateral circulation with rib notch. At age 21, extra-anatomical bypass (from the ascending aorta to the descending aorta) was performed because of persistent upper extremity systemic hypertension. However, systemic hypertension continued to require antihypertensive medication.

Combined Ascending-Abdominal Aortic Bypass and Aortic Valve Replacement for Residual Aortic Coarctation / 日本心臓血管外科学会雑誌

Extra-anatomical aortic bypass through median sternotomy for aortic recoarctation allows concomitant repair of associated cardiac defects while avoiding potential complications of anatomic repair, including hemorrhage, bleeding from adhesions, nerve damage and spinal cord ischemia. We describe here the case of a 13-year-old boy who presented with aortic regurgitation and aortic recoarctation after two previous anatomic repairs with a prosthetic graft through thoracotomies. Ascending-abdominal aortic bypass and aortic valve replacement (AVR) were performed concomitantly through a median sternotomy. Extra-anatomical aortic bypass through a median sternotomy is useful for aortic recoarctation. Careful observation is required for younger patients.

Axillo-Bifemoral Artery Bypass for Atypical Coarctation in an Elderly Patient with Hypertensive Heart Failure / 日本心臓血管外科学会雑誌

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index (ABI) was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8 mm ringed expanded polytetrafluoroethylene (ePTFE) graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.

Solitary Interruption of the Aortic Arch in an Elderly Patient / 日本心臓血管外科学会雑誌

A 67-year-old man was hospitalized due to congestive heart failure. The blood pressure was 180/72mmHg in the right arm and 100/70mmHg in the right leg. Aortography revealed that the aortic arch was completely interrupted just distal to the origin of the left subclavian artery and the descending aorta was clearly outlined by contrast medium coming from well-developed collateral vessels. There was no congenital anomaly such as PDA or VSD except for the interruption of the aortic arch. The final diagnosis was solitary interruption of the aortic arch (type A). An extra-anatomical bypass using a 16mm woven Dacron graft was placed from the ascending aorta to the descending aorta at the level of the diaphragm with cardiopulmonary bypass. The pressure gradient across the interruption disappeared immediately after opening the graft. Although he had perioperative myocardial infarction in the area of the right coronary artery, he recovered fully and when discharged he was in NYHA class 1 condition.

Successful Surgical Treatment of Anactomotic Aneurysm-enteric Fistula / 日本心臓血管外科学会雑誌

A 37-year-old man who had received graft replacement of right iliac artery 20 years ago was admitted to our hospital because of massive intestinal hemorrhage. CT scan and angiogram showed a pseudoaneurysm originating from a graft anastomosis and the case was diagnosed as aorto-enteric fistula. Emergency operation was performed. Following aneurysmectomy and direct closure of split anastomosed portions, colostomy was performed in descending colon. Femorofemoral artery bypass was made as an extra-anatomical bypass. Fortunately, he has been successfully treated and is doing well now. The most important point for the rescue of cases of aneurysm-enteric fistula is to consider such cases of intestinal hemorrhage after the arterial graft replacement in the abdomen.

Successful Emergency Operation for a Ruptured Anastomotic False Aneurysm of Atypical Coarctation Due to Aortitis Syndrome: Report of a Case / 日本心臓血管外科学会雑誌

A 37-year-old female was admitted to our hospital because of haemoptysis. She had undergone descending thoracic aorta-abdominal aorta bypass grafting 11 years previously. Then the diagnosis was atypical coarctation due to aortitis syndrome. No follow up had been continued. Angiogram and CTscan disclosed a false aneurysm at the anastomotic site of the descending thoracic aorta, which was ruptured into the left lung. An emergency operation was performed. A new extra-anatomical ascending aorta abdominal aorta bypass was constructed using 16mm Dacron prosthesis, and three permanent clamps were employed for thromboexclusion of the descending aorta, previous bypass graft and the ruptured aneurysm. At present, three years after the operation, she is leading normal life with medication of hypotensive drugs. Pathogenesis, surgical approach and long-term postoperative care were discussed.