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Dissecting aneurysm of the posterior inferior cerebellar artery (PICA) is a relatively rare disease and its treatment has not been well established. The authors analyzed the clinical and anatomical features of 38 reported lesions and three of our cases to clarify the "best therapeutic modality". The average age was 45.0 years old and 27 patients were male. Left-sided predominance (26 cases) was noted. As to the mode of onset, 23 cases were subarachnoid hemorrhage, 16 were ischemia, and 6 were Wallenberg's syndrome. Anatomically, the sites of dissection were located in the proximal segment of PICA in 31 lesions (75.6%). Review of the cases show that 30 (75%) patients underwent surgical therapy, and 7 (17.5%) patients underwent endovascular treatment. Twenty six patients who took surgical therapy and 5 patients who took endovascular treatment had excellent or good outcome. The critical point in therapeutic procedure is the preservation of perforating branches arising from PICA, therefore surgical trapping with the revascularization of PICA (usually extracranial-PICA anastomosis), in which these tiny branches are secured under microscopic manipulation, has the advantage in principle.

A 45-year-old man presented with enlargement of basilar artery dissecting aneurysm 10 months after suffering brain stem infarction. Combined stenting and placement of Guglielmi detachable coils (GDCs) was planned to obliterate the aneurysm sac. Stent deployment was performed but the procedure was halted to avoid overdosing with contrast material. Cerebral angiography 10 days later showed thrombosis of the aneurysm sac and normalization of the blood flow in the basilar artery. The patient has been followed up for 2 years and showed good clinical and angiographic outcome. Stenting results in obliteration of the aneurysm sac, so a two-stage procedure is recommended.

Successful surgical treatment of chronic dissecting aneurysm (DeBakey IIIb type) in a 50-year-old man was reported. His left lung was tightly adhered to the aneurysm and the chest wall, because he had a previous operation history for pyothorax. This patient showed copious pulmonary bleeding by the pulmonary injury during adhesiotomy. We selected the two stage operation for deducting operation risks, and finished the first operation at the end of adhesiotomy. Some pieces of e-PTFE sheet had been put between lung and thoracic wall, or aneurysm. After a week, waiting the cure of this pulmonary injury, the second operation was performed with a small quantity of pulmonary bleeding. There wasn't fresh pulmonary adhesion because of protection by e-PTFE sheet. The two stage operation was useful in cases associated with dense pulmonary adhesion.

Aorto-right atrium fistula associated with aortic dissection is a very rare complication. Here report a case of successful surgical repair of ascending aortic dissection complicated with aorto-right atrium fistula. A 65-year-old man was presented with sudden chest pain and dyspnea. Fifteen years ago, he had aortic valve replacement. An aortic dissection with fistula to the right atrium was diagnosed by echocardiography and cardiac catheterization. At operation, dense adhesion of the aortic root due to the previous cardiac operation was confirmed, and this was suggested as the cause for this rare complication.

Background: We investigated long-term outcomes of the distal false lumen of the aorta and aortic branches after distal anastomosis of the graft only to the true lumen in chronic type B aortic dissection., Methods: From November 1979 until June 1998, we treated 98 patients without Marfan syndrome who had chronic type B aortic dissection and underwent replacement of the descending aorta, 79 of whom had distal anastomosis to the true lumen only. The celiac artery originated from the false lumen in 11 patients, superior mesenteric artery in 5, right renal artery in 19, and left renal artery in 16., Results: There were 12 (15.1%) early deaths. Spinal cord ischemia was detected in 5 patients. Postoperative follow-up was achieved in 67 patients, and 13 patients died. Postoperative survival at 10 years was 67.6% +/- 7.1%. Eight patients had complete occlusion of the distal false lumen, 54 patients had occlusion of the false lumen down to the celiac artery, and 5 patients had a patent false lumen. Four patients required further replacement of the thoracoabdominal aorta., Conclusions: In non-Marfan patients with chronic type B aortic dissection, the false lumen distal to the graft anastomosis was likely to be thrombosed when the graft was anastomosed to the true lumen only. Postoperative visceral circulation was not compromised, but spinal cord ischemia is a problem that remains to be solved.

A retrospective study was conducted for the surgical treatment on acute aortic dissection among the cardiovascular services of 5 affiliated hospital of medical school. The total of 74 cases were operated for the last 5 years period from Jan., 1991 to Dec., 1995, in which 64 cases were classified as Type A and 10 for Type B. The average age for Type A was 58.4 years old and 10% of patients were consisted of Marfan syndrome. The most frequent complications associated with dissection was aortic regurgitation (37.5%), followed by cardiac tamponade (23.4%). The surgeries were undertaken in less than 24 hours from the onset of symptom in 45.3% of patients. The localization of initial tear as was proved by intraoperative finding was at ascending aorta in 64.0%, whereas it was found at aortic arch in 21.8% of patients. The most frequent application of operative procedure was simultaneous graft replacement of ascending aorta and aortic arch (68.7%) with the use of profound hypothermia and antegrade selective cerebral perfusion (85.4%). The overall mortality rate was 25.0%, however when compared as ascending only vs ascending + arch replacement, the later group demonstrated higher mortality rate (16.6% vs 28.9%). The majority of surgical indication for Type B was hemorrhage from the dissection and 20.0% of mortality was recorded in this group of patients.

The first prominent report on the surgical treatment for acute aortic dissection was published by DeBakey in 1975. Since then, many various techniques have been applied for the surgery on dissection at ascending aorta and aortic arch. The basic understanding for the surgical treatment are focused to the climination of intimal tear as well as resection and closure of dissecting lumen and restore the blood flow only to the true lumen. The associated complications such as acute dissection AR should also be repaired simultaneously. At the present, the graft replacement of ascending aorta has become first choice of procedure. No matter where the intimal tear is located, the simultaneous replacement of assending aorta and aortic arch has been proposed recently as the most radical approach toward Type A dissection, although this extended approach has to be carefully evaluated in the future.

Objectives: This study reports surgical experience of 72 cases of aortic dissection with intimal tear in the transverse aortic arch., Methods: Of 325 patients with aortic dissection, 72 (22.2%) had a tear in the arch, including 27 with acute dissection and 45 with chronic dissection. Mean age at surgery was 60.8 +/- 14.1 years. The dissection was localized from the ascending aorta to the arch in 30 patients and extensive from the ascending aorta to the descending aorta in 42. Surgeries consisted of total arch replacement in 50 patients, hemiarch replacement in 20, and extra-anatomical bypass in 1. In the initial series, cardiopulmonary bypass for brain protection during arch procedures was selective cerebral perfusion (61 patients), but since July 1993 deep hypothermic circulatory arrest with retrograde cerebral perfusion was exclusively utilized (8 patients)., Results: Hospital mortality was 9.7%, 11.1% of the patients who had acute dissection and 8.8% with chronic dissection. There has been no mortality since February 1993. The mean follow-up period was 51 +/- 37 months, and there were 3 late deaths. The 5 and 10 year survival rate was 85.3 +/- 4.8 in all patients, 84.3 +/- 8.9% with acute dissection, and 85.5 +/- 5.7% with chronic dissection. The 5 and 10 year survival was 79.8 +/- 7.1 with extensive dissection, and 93.5 +/- 6.5% with localized dissection. During follow-up, 6 patients underwent subsequent aortic surgeries. The freedom from reoperation at 5 years and at 10 years was 91.4 +/- 4.8% and 65.6 +/- 14.4%, respectively. In patients with acute dissection it was 92.3 +/- 7.4% and 61.5 +/- 25.6% at 5 years and 10 years, while with chronic dissection it was 87.0 +/- 7.0% and 44.0 +/- 17.3% at 5 years and 10 years, respectively (n.s.). The freedom from subsequent reoperation for the aorta in all patients was 91.4 +/- 4.8% at 5 years and 10 years was 65.6 +/- 14.4%. With acute dissection it was 92.3 +/- 7.4% at 5 years and 61.5 +/- 25.6% at 10 years, while that with chronic dissection it was 91.3 +/- 5.9% and 65.7 +/- 16.8% at 5 years and 10 years respectively (n.s.). The freedom from all reoperations with extensive dissection at 5 years and 10 years was 86.6% +/- 7.2% and 34.2 +/- 17.3%, respectively, moreover, the freedom from reoperations with localized dissection at 5 and at 10 years was 90.0 +/- 9.5% (n.s.). However, the freedom from subsequent aorta reoperation with extensive dissection at 5 years and 10 years was 86.6 +/- 7.2% and 56.0 +/- 16.0%, respectively, while with localized dissection it was 100% at 10 years (P < 0.01)., Conclusion: Early and late surgical result for arch dissection was satisfactory with a surgical principle of resecting the aortic segment that contains the initial intimal tear and graft replacement.

We performed simultaneous graft replacement of the total aortic arch and ascending aorta for type A aortic dissection with a patent false lumen extending through the arch into the descending or abdominal aorta. During the past 7 years, this procedure was performed in 42 patients (28 men and 14 women), aged 20 to 72 years (mean age, 50 years). Nineteen patients underwent the procedure during the acute period, and 23 during the chronic period. The site of the initial intimal tear was the ascending aorta in 17 patients and the transverse aortic arch in 25 patients. Artificial graft replacement was initially accomplished by proximal anastomosis, followed by open distal anastomosis, and finally by anastomosis of each of the three arch vessels. There were 3 hospital deaths (7.1%), 1 resulting from acute dissection (5.3%) and 2 from chronic dissection (8.7%). Among the type A dissections, total arch graft replacement has been indicated in the setting of rupture of the aortic arch, arch dissection, and Marfan's syndrome. However, with increasing experience in arch reconstructions and improvement in outcome, the indications could be expanded to include all type A aortic dissections with a patent false lumen in the descending aorta.

It is obvious that there are many controversies regarding to the treatment of aortic dissection. In this report, we discuss following points such as 1) classification, 2) thrombosed type dissection, and 3) simultaneous graft replacement of ascending and aortic arch with the reconstruction of cervical branches. From the patho-morphological status, dissection will be classified into two types, localized and extended types. From the anatomical and surgical points of view, it will be also classified as 1) ascending-arch, 2) descending-thoracoabdominal, and 3) abdominal. With the combination of these two, dissection will be classified more clearly. The thrombosed type will be incorporated into localized type. We have experienced 76 cases of this dissection, and clinical features and outcome by medical treatment only are presented. The simultaneous reconstruction of ascending aorta and aortic arch for the dissection at ascending-arch type was undertaken in total of 35 patients. The surgical results as well as follow up data are presented and the benefit of this extended procedure is presented as well.

The authors examined 17 patients with type A aortic dissection with ultrafast computed tomography (CT). Forty sections with 1-cm intervals, from the aortic arch to the aortic bifurcation, were scanned serially without breath holding within only 74 seconds. Except for two thrombosed dissections, all intimal flaps in the ascending aorta were demonstrated, and 14 (93%) of the 15 surgically proved intimal tears were depicted. An intimal tear in the aortic arch was missed. Since conventional scanning tends not to depict type A aortic dissection, millisecond-order ultrafast CT scanning has the potential to become the modality of choice for imaging of aortic dissection.

A 37-year-old female with Marfan's syndrome developed myocardial infarction during a cardiac operation for annuloaortic ectasia and chronic dissecting aneurysm of the aorta. At autopsy, a chronic dissecting aneurysm of the left coronary arterial system (the left main stem, anterior descending branch, first diagonal branch, and circumflex branch) showing a true lumen and a pseudo lumen, which were patent, was found. There was also a hemorrhagic myocardial infarction of the anteroseptal wall and apical portion of the left ventricle.

Twenty-seven patients, whose renal artery (or arteries) originated from false lumen, were studied dividing into two groups based on pre-operative renal state. Group I, without morphological and functional disorder, did not show any change pre- and post-operatively. Post-operative angiography indicated that pre-operative re-entry played as a entry to perfuse the false lumen originated renal artery (or arteries). In group II, with morphological and/or functional disorder, renal arteries, with reduced flow or non-perfused, originated from false lumen in 4 patients and true lumen in 4. Kidney perfused by those arteries had been disturbed morphologically more or less. So, it was not only the reason of renal disturbance that the false lumen originated arteries perfused that kidney. Post-operative enhanced body CT showed that false lumen of descending Ao without major entry or leakage at the site of anastomosis was occluded completely by thrombus formation in 11 of 12 patients. In those 11 patients, false lumen of upper abdominal Ao did not have any thrombus formation and gave enough flow to perfuse kidney. Those suggest that the operation resecting entries does not influence the renal function, the reason of renal disorders in DAA is not to be perfused by false lumen originated arteries but a grade and duration of renal ischemia and the residual flow of false lumen decides making thrombus formation or not.

Eighteen patients with DAA IIIb were divided into two groups. Seven patients with major abdominal arteries originated from true lumen (group I) and 11 ones with renal artery or arteries from false lumen (group II). group I: In early postoperative phase (25-55 days), the descending aortic false lumen had been thrombo-occluded in all patients and the upper abdominal aortic false lumen had been still enhanced in three. In late postoperative phase (9-35 mos.), false lumen had been disappeared in three patients, so those aortae appeared normal morphologically and in other three patients thrombo-occluded false lumen reduced in size. group II: There were re-entries and the false originated renal arteries were well perfused in all patients. In nine patients with no leakage at anastomotic site, these descending aortic false lumens were thrombo-occluded. But as in the upper abdominal aortic false lumens, there was still enough blood flow to perfuse the false originated renal arteries. These suggest that the complete entry closure is the most important, so we recommend to graft the descending aorta containing entry with prosthesis, and this operation leads false lumen to 1) thrombo-occlusion, 2) absorption of thrombus and finally 3) normalization of injured aorta morphologically.

The fate of false lumens in 13 patients having Type III aortic dissections was studied using computed tomography (CT). Contrast media filled false lumens with or without thrombosis were observed in ten patients; the false lumens of three patients were entirely thrombosed at initial examination. Follow-up CT studies showed shrinkage or disappearance of the false lumens with thrombosis in four patients, progression of thrombosis in two patients, and enlargement of the false lumen in one patient who subsequently required surgical repair. No change was observed in the remaining six patients during our observation period. CT study provides useful information for evaluating the efficacy of medical treatment and the timing of surgical intervention during follow-up evaluation of medically treated Type III aortic dissections.