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Chronic type B aortic dissection with the right aortic arch was rare. We present the case of a 59-year-old man with a right aortic arch and chronic type B aortic dissection, with a maximum size of 80 mm. Graft replacement was successfully performed through right anterolateral thoracotomy with partial sternotomy through the fourth intercostal space. The patient's postoperative course was uneventful. He had no paralysis and was extubated on postoperative day 2 and discharged from the hospital on postoperative day 15. Anterolateral thoracotomy with partial sternotomy could be a suitable approach for right-sided aortic aneurysms.

Objective: The outcomes of emergency surgery for type A acute aortic dissection have improved. However, ascending aortic replacement sometimes leads to dilatation of the distal aorta. The present study reviewed our outcomes of ascending aortic replacement and total arch replacement in patients with type A acute aortic dissection., Methods: A total of 253 patients with type A acute aortic dissection underwent a central repair operation. Our standard technique was ascending aortic replacement. Total arch replacement was performed only when entry existed in the major curvature of the aortic arch and the proximal descending aorta. A total of 169 patients (67%) underwent ascending aortic replacement, and 84 patients (33%) underwent total arch replacement. Hospital death due to initial surgery, dilatation of the distal aorta greater than 5 cm, new occurrence of aortic dissection, any distal aortic surgery, and aortic-related deaths were defined as distal aortic events., Results: The mortality was 7.1% in the ascending aortic replacement group and 6.0% in the total arch replacement group. Postoperative computed tomography was performed in 162 patients in the ascending aortic replacement group. The false lumen of the residual aortic arch had thrombosed and healed in 94 patients (58%) and remained present in 68 patients (42%). The distal aortic event-free rate in the ascending aortic replacement group decreased from 74% at 5 years to 51% at 9 years, and the rate in the total arch replacement group was 83% at 5 to 9 years (P < .01). For the ascending aortic replacement group, more patients with a dissected arch had a distal aortic event compared with patients with a healed arch (P < .01)., Conclusions: Total arch replacement was associated with fewer distal aortic events. We may expand the indications for total arch replacement in stable patients., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative stroke is a serious unsolved complication after acute type A aortic dissection (ATAAD) repair. We investigated the incidence and risk factors of stroke, and hypothesized that dissection of supra-aortic vessels is an important risk factor of this morbidity., Methods: Between 2012 and 2019, 202 (56% men, median age 68 years) patients with ATAAD underwent surgical repair. Clinical data, image findings, method of circulatory support, and repair technique were retrospectively investigated to explore the risk factor of postoperative stroke., Results: Of the 202 patients, operative mortality was 6% and the incidence of postoperative stroke was 12% (n = 25). Brachiocephalic artery (BCA) dissection was associated with a higher risk of stroke (odds ratio, 3.89; 95% confidence interval, 1.104-13.780; p = .035) having no relation to the presence or absence of left common carotid artery dissection. Preoperative malperfusion syndrome, circulatory arrest time, isolated cerebral perfusion time, repair technique (total arch replacement), and femoral artery perfusion alone were not related to the incident rate of postoperative stroke. Stroke occurred in both hemispheres, regardless of the laterality of carotid artery dissection., Conclusion: BCA dissection was an independent risk factor of stroke after ATAAD repair., (© 2021 Wiley Periodicals LLC.)

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

Objective: The control of malperfusion is the key to improving the outcomes of surgery for type A acute aortic dissection. We revised our treatment strategy to reperfuse each ischemic organ before central repair., Methods: Our current early reperfusion strategy consists of percutaneous coronary artery intervention for coronary malperfusion, direct surgical fenestration for carotid artery occlusion, active perfusion of the superior mesenteric artery for visceral malperfusion, and external shunting from the brachial artery to the femoral artery for lower limb ischemia. Central repair is performed without delay after reperfusion therapy, but if irreversible organ damage is recognized, further aggressive treatment is discontinued., Results: Among 438 patients who underwent initial treatment for type A acute aortic dissection, malperfusion in one or more organs was diagnosed in 108 patients (24%). We applied an early reperfusion strategy in 33 patients, (coronary, 14 patients; carotid, 4; visceral, 7; lower extremity, 8). Central repair was then performed in 28 patients. One patient (3.6%) died of pneumonia; 27 patients overcame the ischemic organ damage and survived. Among the 108 patients with malperfusion, 10 patients (9.3%) were treated medically without early reperfusion and central repair. During the same period, mortality from central repair procedures in patients with malperfusion who had not received early reperfusion therapy was 12 of 65 (18%), and the mortality of patients without malperfusion was 9 of 262 (3.4%). Malperfusion was a serious risk factor for hospital death, but the mortality rate of the patients with an early reperfusion strategy was significantly (P < .01) lower than the patients without early reperfusion., Conclusions: Our strategy might improve the outcomes of surgery for type A acute aortic dissection with malperfusion. This strategy enables us to avoid unproductive central repair procedures in irreversibly damaged patients., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The relationship between aortic dissection and coronary artery disease is not clear. The purpose of this study was to clarify the difference in the rate of coronary artery atherosclerosis between Stanford type A and type B aortic dissection by reviewing our institutional database., Methods: One hundred and forty-five patients (78 males, 67 females; mean age: 60 ± 12 years) admitted to our hospital with acute aortic dissection who underwent coronary angiography during hospitalization from 2000 through 2002 were enrolled in this study. The background characteristics, coronary risk factors, and coronary angiography findings (number of significant stenoses, stenoses according to Bogaty standards, extent index) of patients were compared between type A (Group A; n = 71) and type B dissection (Group B; N = 74)., Results: Significantly more patients had prior histories of complications from ischemic heart disease in Group B than in Group A (P = 0.04), with no significant differences in comparison to other risk factors observed except for hypertension. Significantly (p = 0.005) more stenoses were observed in Group B (1.54 ± 0.04) than in Group A (0.38 ± 0.1). A significantly higher (P < 0.05) index score indicating the severity of coronary atherosclerosis was observed in Group B (1.49 ± 0.09) than in Group A (0.72 ± 0.07)., Conclusions: Stanford type B acute aortic dissection was significantly more frequently associated with coronary artery atherosclerosis than type A.

The procedure and efficacy of the intermittent distal perfusion during hypothermic circulatory arrest in total arch replacement was described. During hypothermic circulatory arrest, elephant trunk was fixed inside the descending aorta. Then, the AP Grid Catheter was inserted through the elephant trunk, and blood perfusion at a flow rate of 500 ml/min for 5 min was installed. After the perfusion, distal anastomosis was completed. Clinical results of 23 patients (Group I) with this technique were compared with these of 21 patients without the procedure (Group II). Continuous hypothermic circulatory arrest time was significantly shorter (32.7 vs. 72.7 min; p < 0.05) and postoperative serum creatinine level was significantly lower (1.29 vs. 1.68; p < 0.05) in Group I than Group II. The incidence of abdominal complication was also fewer in Group I. Intermittent distal perfusion shortens hypothermic circulatory arrest time and is protective for the lower body including kidneys.

Our treatment strategy for acute type B aortic dissection (ABAD) included complicated type is as follows. Indications of thoracic endovascular aortic repair (TEVAR) for ABAD are rupture and organ ischemia, and TEVAR has been the 1st line central repair therapy since January 2009 in our institution. At the time of TEVAR for ruptured communicating type ABAD, we usually seal the proximal entry tear and cover the existing range of hematoma at descending aorta. Procedures for ABAD with malperfusion should be changed according to the patient's condition such as branch vessel obstructions either dynamic type or static type. We select TEVAR for ABAD with malperfusion in order to prevent late aortic events as well as treat the dynamic malperfusion. For complicated ABAD patients with poor condition and hemodynamic instability, TEVAR achieving central repair rapidly and less-invasively is considered an advantageous procedure. We usually pay attention how to use TEVAR and how to combine with other therapies for complicated ABAD treatment.

Acute type A aortic dissection (AAAD) remains a lethal disease. With advances in operative methods and perioperative management, surgical outcomes continue to improve, but in-hospital mortality still ranges from 10 to 30% in most series. The surgical technique of choice for aortic root repair remains controversial. Surgical glue created a breakthrough in surgery for acute aortic dissection. We review the surgical techniques with the use of surgical glue for AAAD.

Objectives: The purpose of this study was to evaluate the clinical outcomes of emergency surgery for acute type B aortic dissection with rupture and to compare results between open surgery and thoracic endovascular aortic repair (TEVAR)., Methods: Two hundred and ninety-four patients with acute type B aortic dissection were admitted to our hospital between January 2000 and March 2012. At presentation, 30 (10%) patients had rupture (20 men, 10 women; mean age, 71 ± 15 years), among whom 23 underwent emergency surgery: 9 underwent TEVAR and 14 underwent open surgery. The objective of TEVAR was closure of the primary entry site and the secondary tear site in the descending thoracic aorta., Results: In the TEVAR group, technical success was achieved: the primary entry site was closed, and bleeding was controlled in all 9 patients. There was no operative death, and 1 (13%) patient had cerebral infarction. In the open surgery group, 2 (14%) patients died during hospitalization, and 4 (29%) had cerebral infarction in the acute phase. Hospitalization tended to be longer in the open surgery group than in the TEVAR group. The overall survival rate at 1 year was 71 ± 17% in the TEVAR group and 86 ± 9% in the open surgery group (P = 0.89)., Conclusions: TEVAR for acute type B aortic dissection with rupture could be performed with relatively low morbidity and mortality, with no significant difference when compared with open surgery. The main objective of TEVAR for acute type B aortic dissection with rupture is control of bleeding, which can be achieved by closing the primary entry site and the secondary tear site in the descending thoracic aorta. If anatomically feasible and performed immediately, TEVAR is the treatment of choice for acute type B aortic dissection with rupture because it is less invasive than open surgery.

Purpose: To study mid-term outcomes in patients admitted to receive treatment for acute type B aortic dissection., Methods: The study group comprised 229 patients with acute type B aortic dissection treated between January 2000 and July 2010. 128 patients had a thrombosed false lumen, and 101 had a patent false lumen., Results: In the thrombosed group, 6 had rupture, 4 had malperfusion, and 118 had no complications. There were 5 early deaths (3.9%). In the patent group, 12 had rupture, 19 had malperfusion, and 70 had no complications. There were 6 early deaths (5.9%). Overall survival rates in the thrombosed group and the patent group were 94.7 ± 2.2% and 90.2 ± 3.2% at 1 year, and 84.3 ± 4.6% and 85.9 ± 4.3% at 5 years (p = 0.892), respectively. Aorta-related event-free rates were 85.6 ± 3.4% and 48.3 ± 5.5% at 1 year, and 76.0 ± 5.1% and 35.2 ± 7.2% at 5 years (p <0.001), respectively., Conclusions: The incidences of rupture and malperfusion during the acute phase were higher in the patent group compared with the thrombosed group. At the late period, although the aorta-related event rate was higher in the patent group, the survival rate did not differ between two groups. Close follow-up and aggressive intervention strategy of the patent group may result comparable outcomes with the thrombosed group.

Aortic aneurysm and/or dissection (AAD) is a life-threatening condition, and several syndromes are known to be related to AAD. In this study, two new technologies, resequencing array technology (ResAT) and next-generation sequencing (NGS), were used to analyze eight genes associated with syndromic AAD in 70 patients with non-syndromic AAD. Eighteen sequence variants were detected using both ResAT and NGS. In addition one of these sequence variants was detected by ResAT only and two additional variants by NGS only. Three of the 18 variants are likely to be pathogenic (in 4.3% of AAD patients and in 8.6% of a subset of patients with thoracic AAD), highlighting the importance of genetic analysis in non-syndromic AAD. ResAT and NGS similarly detected most, but not all, of the variants. Resequencing array technology was a rapid and efficient method for detecting most nucleotide substitutions, but was unable to detect short insertions/deletions, and it is impractical to update custom arrays frequently. Next-generation sequencing was able to detect almost all types of mutation, but requires improved informatics methods.

Background: Stanford type A acute aortic dissection is a fatal condition requiring emergency surgery. This study was designed to evaluate risk factors for hospital mortality in patients with Stanford type A acute aortic dissection., Methods: We studied consecutive 301 patients (163 men and 138 women; mean age, 63.3 years) who underwent emergency surgery for Stanford type A acute aortic dissection from January 1997 through December 2007. The subjects were divided into two groups: patients who were discharged from the hospital, and those who died during hospitalization. Preoperative and operative clinical factors were compared between the groups., Results: Overall, 41 patients (13.6%) died during hospitalization. On univariate analysis, significant preoperative risk factors for hospital mortality were cardiopulmonary resuscitation, coagulopathy, renal dysfunction, elevated aspartate aminotransferase levels, myocardial ischemia, and lower-extremity ischemia. As for factors related to surgery, the duration of operation, cardiopulmonary bypass time, aortic cross-clamp time, and volume of blood transfusion were greater among patients who died during hospitalization than in those who were discharged from the hospital. On multivariate analysis, independent preoperative risk factors were cardiopulmonary resuscitation, renal dysfunction, and lower-extremity ischemia. Shock or cardiac tamponade were not risk factors., Conclusions: Risk factors for hospital mortality in patients with Stanford type A acute aortic dissection were cardiopulmonary resuscitation, renal dysfunction, and lower-extremity ischemia., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Acute type A aortic dissection remains a lethal disease. With advances in operative methods and perioperative management, surgical outcomes continue to improve, but in-hospital mortality still ranges from 10% to 30% in most series. The surgical technique of choice for aortic root repair remains controversial. Thus, we review the surgical techniques and introduce endovascular stent graft treatment and genetic studies for acute type A aortic dissection.

Background: Although gelatin-resorcinol-formaldehyde (GRF) glue is used for surgical repair of acute type A aortic dissections, late complications possibly ascribed to toxic effects of GRF glue have been reported. We analyzed the benefits and risks of using GRF glue., Patients and Methods: Between January 1990 and August 2003, 269 consecutive patients underwent emergency operations for acute type A aortic dissection. GRF glue was not used in 47 patients (non-GRF group) who were operated on until May 1995 and was used in the 222 (GRF group) who underwent operation subsequently., Results: The rate of in-hospital mortality was significantly higher in the non-GRF group (31.9%) than in the GRF group (12.6%) (p<0.0001). In the GRF group, false aneurysms were found in 31 patients (31/194 survivors, 16.0%) 1-65 (mean, 30+/-18) months after initial operation. Reoperation was done in 24 of these patients. At reoperation, the site to which GRF glue was applied had degenerated, and the anastomosis between the aortic root and prosthesis had opened widely, creating a false aneurysm and resulting in aortic regurgitation with prolapse of the coronary cusps. The mortality rate of reoperation was 4.2% (1/24)., Conclusion: The use of GRF glue improved the short-term outcome of surgery for acute type A aortic dissection, but was associated with a high incidence of false aneurysms forming at the site of proximal anastomosis, where GRF glue had been applied. Patients in whom GRF glue has been used should be carefully followed up after surgery.

Objective: Transluminal endovascular grafting (TEG) is less invasive than conventional operative procedures for the treatment of DeBakey type III dissecting aortic aneurysms (DAA). We have used two different kinds of stent grafts covered with woven Dacron grafts, a Gianturco Z-stent graft (G-SG) and a Spiral Z-stent graft (S-SG). Because the G-SG lacks adequate flexibility, the end of the graft may injure the intima after long-term deployment in the proximal descending aorta. We have used S-SGs, which are more flexible than G-SG, to improve outcome. We report our late midterm results and discuss treatment policy., Subjects and Methods: We studied 45 patients with DeBakey type III DAA. Thirty-two G-SGs and 13 S-SGs were used. Follow-up ranged from 1 year 6 months to 8 years 5 months (mean, 5 years 2 months)., Results: 1) Surgical outcome: (a) TEG was technically successful in all patients. There was no operative mortality. (b) One week after surgery, 36 patients had no endoleaks, 5 had minor endoleaks, and 4 had major endoleaks. 2) Late midterm results: (a) Four patients with residual major endoleaks, underwent replacement of the descending thoracic aorta. (b) Intimal injury occurred at the distal end of the stent graft 4 to 18 months (mean, 10.5 months) after surgery in 12 patients with G-SG and 1 with S-SG. One of these patients had recurrent dissection, and 12 had ulcer like projections (ULP). Two patients underwent additional stent implantation to block blood flow. (c) Four patients with S-SG had major endoleaks 3 to 6 months after surgery. In 3 of these patients, the Spiral Z-stents were compressed and occluded, and thrombus had formed in the lumen. Three patients underwent replacement of the descending thoracic aorta. (d) Additional replacement of the descending thoracic aorta was done in 9 of the 45 patients (20%) 4 to 24 months after TEG. All patients responded to treatment and were discharged from the hospital., Conclusion: Intimal injury was caused by Gianturco Z-stents because of inadequate flexibility, and endoleaks and stent-graft occlusion were caused by Spiral Z-stents because of insufficient radial force against the aortic wall. The development of stents with these improved properties is expected to further improve outcome.

Purpose: To report successful endovascular repair of Stanford type A acute aortic dissection associated with a proximally extended dissection of the left main coronary artery., Case Report: A 71-year-old man presented with acute type A aortic dissection. One day after admission, dissection of the left main coronary artery accompanied by severe myocardial ischemia prompted Palmaz stent placement. Three days later, a customized stent-graft was placed across the entry site of the dissection in the descending aorta. The false lumen in the ascending aorta, transverse arch, and the descending thoracic aorta thrombosed, and the left coronary artery remained patent. At 14 months after the procedures, the patient is doing well and has had no cardiac event., Conclusions: This staged procedure may be one option for the management of acute type A aortic dissection complicated by coronary artery dissection.