Successful Endovascular Repair of a Kommerell's Diverticulum and a Right-Sided Aortic Arch.

BACKGROUND: A 57-year-old woman was diagnosed with Kommerell's diverticulum in the setting of a right aortic arch on computed tomography. CASE REPORT: Although asymptomatic, the maximum diameter of the aneurysm was 55 mm; thus, she underwent surgery to prevent rupture of the aneurysm. A bypass was constructed from the left common carotid artery to the left subclavian artery. A stent-graft was deployed from the distal right subclavian artery, and coil embolization of the diverticulum was performed via the left subclavian artery. She was discharged after 12 days of surgery. The postoperative four-month follow up showed a smaller aneurysm. CONCLUSION: Thoracic endovascular aortic repair is feasible and effective for Kommerell's diverticulum.

Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair for Type B Dissection.

BACKGROUND: A 64-year-old woman presented with dilatation of the distal aortic arch secondary to chronic type B aortic dissection. CASE REPORT: The patient underwent fenestrated thoracic endovascular aortic repair (TEVAR) for closure of the entry site, and reconstruction of the left subclavian artery with a covered stent. On the 40th postoperative day, a retrograde type A aortic dissection (RTAD) was observed on computed tomography and she underwent emergency surgery. The entry tear, related to the proximal bare metal stent, was located in front of the aortic arch. A partial aortic arch replacement was performed. CONCLUSION: Consideration of the risk factors of RTAD is important when performing TEVAR.

[Stanford type B aortic dissection associated with coarctation of the aorta].

We report a rare case of type B aortic dissection associated with coarctation of the aorta. A 35-year-old man had sudden dyspnea and severe back pain. Computed tomography revealed aortic coarctation at the distal aortic arch, and aortic dissection below the coarctation. The diameter of proximal descending aorta was enlarged to 52 mm. We electively performed excision of aortic coarctation and descending aortic graft replacement. Coarctation of the aorta has a poor prognosis, The risk of aortic rupture due to aortic dissection is very high, and the histological abnormality is also pointed out. Therefore we should perform aggressive surgical treatment.

[Reoperation for a giant aortic arch aneurysm using cervical cannulation of the common carotid artery for cerebral perfusion after the ascending aortic replacement; report of a case].

Reoperation for a giant thoracic aneurysm touching the sternum needs to be performed with special precautions. The patient was a 65-year-old man who had undergone ascending aortic replacement due to acute Stanford type A dissection 5 years previously. He visited an outpatient clinic after an interval of 4 years, and was diagnosed with an aortic arch aneurysm which was touching the sternum. Preoperative examinations suggested a high risk of rupture if resternotomy was performed. Therefore, we performed resternotomy under cardiopulmonary bypass. In addition, the left carotid artery was secured for cerebral perfusion through a neck incision, which enabled core cooling in case of uncontrollable hemorrhage. He successfully underwent aortic arch replacement, and he was discharged without any neurological complications.

Emergency off-pump complete arterial revascularization in a patient with dextrocardia.

We describe complete emergency arterial coronary artery bypass grafting performed on the beating heart of a 73-year-old man with situs inversus totalis and triple-vessel disease. The right internal mammary artery was anastomosed to the left anterior descending artery in situ. The first and second obtuse marginal branches of the circumflex coronary and the posterior descending branch of the right coronary artery were sequentially revascularized using the left internal mammary and radial arteries in situ. The only abnormality was that the position of the heart mirrored that of a normal heart. Beating heart surgery appears to be as safe in patients with dextrocardia as in the general population. However, the position of the surgeon must be reconsidered for optimal handling of stabilizers and to facilitate access to anastomosis sites. Understanding mirror-image coronary arterial anatomy is important for successful surgical outcomes among patients with dextrocardia.

Unexpected hemodynamic deterioration and mitral regurgitation due to a tissue stabilizer during left anterior descending coronary anastomosis in off-pump coronary artery bypass graft surgery.

We have experienced three rare cases of hemodynamic deterioration and transient mitral regurgitation (MR) induced by a suction-type tissue stabilizer during the left internal thoracic artery (LITA)-to-LAD (left anterior descending) coronary artery anastomosis. Transesophageal echocardiogram (TEE) showed new or worsening MR during the placement of a tissue stabilizer. In all three cases, the positioning of the stabilizer was difficult to secure a good surgical field, because the LAD coronary artery migrated deep into the myocardium. This anatomical variation seemed to require a stronger fixation of the stabilizer to the heart. We concluded that compression of the left ventricular (LV) wall may have possibly caused morphologic changes of the LV and the distortion of the annulus of the mitral valve. These changes are thought to have caused decreased LV filling and the MR, which led to an unexpected hemodynamic deterioration.