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OBJECTIVES We present our experience of total aortic arch replacement. METHODS Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years. CONCLUSIONS Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES Presenting a surgical strategy for aorto-oesophageal fistula (AEF). METHODS From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed. RESULTS Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction. CONCLUSIONS Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment. [ABSTRACT FROM AUTHOR]

The elephant trunk technique is used as a standard method in the approach to staged repair of extensive thoracic aneurysms. Here, we present a rare case of a graft infection, in which vegetation was attached to the distal end of the elephant trunk. A 36-year old male who had undergone total arch replacement with elephant trunk installation for type A aortic dissection was readmitted for high-grade fever. At the time of admission, Osler's nodules were present and brain magnetic resonance imaging showed multiple small emboli and haemorrhages. Transoesophageal echocardiography could not locate any sign of infection within the cardiac chambers, but disclosed vegetation attached to the elephant trunk. He underwent successful emergent graft replacement of the lesion, and no recurrence of the infection has been observed. [ABSTRACT FROM AUTHOR]