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We encountered a rare case of infection in a vascular graft created using the elephant trunk technique. A 65-year-old woman who underwent total arch replacement with the elephant trunk technique was re-admitted with fever. She developed embolization of multiple organs from vegetation attached to the elephant trunk graft which was elucidated by transesophageal echocardiography. Surgery for ruptured jejunal artery aneurysm was performed, and the graft infection healed after long-term antibiotic therapy with the prosthesis left in situ. Graft infection may generate vegetations on an elephant trunk graft. Transesophageal echocardiography is a helpful tool for accurate diagnosis.

In aortic arch surgery, we reconstruct branches before opening the arch to avoid cerebral embolism of the debris derived from the aortic wall. We made a trifurcated graft for branch reconstruction using 10 mm and 8 mm polyester grafts. Cardiopulmonary bypass started under right axillary perfusion and venous drainage through the right atrium. While cooling, the left subclavian artery was clamped and anastomosed to the end of the trifurcated graft. Then the ascending aorta was cross-clamped and cardioplegic solution was infused. At 25 degrees centigrade of the tympanic temperature, the left carotid artery is clamped and anastomosed to the branch of the trifurcated graft with or without perfusion into the left carotid artery. Subsequently the brachiocephalic artery was reconstructed in the same manner. After antegrade cerebral perfusion was established through the trifurcated graft via right axillary perfusion, distal anastomosis of the aortic arch was done with the open distal technique. Graft-graft anastomosis was followed to reperfuse the lower half of the body. Finally proximal anastomosis was performed to complete total arch replacement. Forty-four patients underwent total arch replacement in this technique. In-hospital mortality was 4.5%. Cerebral infarction occurred in 4.5% of the patients probably due to embolization of the debris derived from the branches of the aortic arch.

In this article, we report the case of a 68-year-old woman who presented with shortness of breath. Respiratory function tests showed a slightly obstructive physiology. Computed tomography (CT) results revealed an aberrant left subclavian artery and a Kommerell diverticulum arising from a right-sided aortic arch that was compressing the trachea and the surrounding tissues. A median sternotomy was performed with the patient under circulatory arrest with moderate hypothermia, and a transaortic stent graft was inserted to exclude the Kommerell diverticulum. The aberrant left subclavian artery was ligated and an axillo-axillar bypass was constructed. Postoperative CT showed complete exclusion of the Kommerell diverticulum without an endoleak. The patient's breathing difficulty was resolved, and she was discharged uneventfully. This procedure should be considered as an alternative strategy for exclusion of Kommerell diverticulum., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: In order to determine whether critical intercostal artery is present in the aneurysm during descending thoracic or thoracoabdominal aortic surgery, changes of transcranial motor-evoked potentials (Tc-MEPs) were monitored following infusion of cold blood into the aorta as an adjunct 'on-site assessment'. Accuracy of this method was evaluated., Methods: Fourteen patients were examined for Tc-MEPs changes following infusion of cold blood (4 degrees C, 300-450 ml) into the aneurysm. The intercostal arteries in the aneurysm were reconstructed when the Tc-MEPs amplitude decreased to below 50% of the baseline within 3 min after cold blood infusion. When the amplitude did not decrease, every intercostal artery in the aneurysm was ligated., Results: The Tc-MEPs amplitude did not decrease in eight cases (57%), while it decreased in six cases (43%). In the former, no case presented with paraplegia despite every intercostal artery being ligated. In the latter, the amplitude recovered after reconstruction in four patients, who had no paraplegia postoperatively. In the remaining two cases, however, the amplitude did not recover: one died of multiple organ failure with postoperative assessment unfeasible; the other developed paraplegia following surgery. Except one case with operative death, both sensitivity and specificity of our criteria with cold blood infusion was 100% in this series., Conclusions: Cold blood infusion into the clamped segment of aorta accelerates Tc-MEPs changes and can possibly reduce ischemic insults of spinal cord during diagnostic process, while it accurately detects presence of critical intercostal artery in the segment. This method appears to be promising adjunct on-site assessment.

Objectives: Although endovascular stent-grafting is available for atherosclerotic thoracic aneurysms, it is unknown whether the excluded thrombosed aneurysms shrink. We evaluated serial changes in distal aortic arch or proximal descending aortic aneurysms excluded space after transaortic stent-grafting., Methods: Thirty-four patients with true distal aortic arch or proximal descending thoracic aortic aneurysms were treated by stent-grafts introduced via proximal arch aortic incisions. Follow-up included computed tomographs (CT) every 6 months in 31 patients. The maximum dimensions for excluded space and aneurysmal diameters were measured and evaluated to determine whether the aneurysmal space had decreased or shrunken following this alternative procedure., Results: Two hospital deaths (5.9%) were caused by a cerebral embolism and a peri-operative myocardial infarction. Another case died from pneumonia a year after surgery. Thirty-one cases (91%) survived during follow-up, but one case suffered from paraplegia (2.9%). The follow-up period ranged from 10 to 72 months (average 39.3+/-27.2 months). There were no aneurysmal ruptures during follow-up. Post-operative serial CTs showed a disappearance or a significant shrinkage of the excluded aneurysmal space in 30 of the 31 cases (97%); one case suffered endoluminal leakage., Conclusions: Transaortic endovascular stent-grafting is feasible for distal aortic arch or proximal descending aortic aneurysms. The excluded aneurysmal space disappears or shrinks after successful stent-graft placement.

Background: The purpose of this study was to evaluate the midterm results of transaortic stent-grafting for distal aortic arch aneurysms or proximal descending aortic aneurysms and the feasibility of this method for thoracic aortic aneurysm repair., Methods: Twenty-three patients with true distal aortic arch aneurysms or proximal descending thoracic aortic aneurysms were repaired with the stent-graft introduced through the incision on the proximal arch aorta. Follow-up computed tomography was performed every 6 months in 21 surviving patients. The maximum dimension of the excluded aneurysmal space and the maximum aneurysmal diameter were measured and evaluated to determine whether the aneurysmal space decreased or disappeared after this alternative procedure., Results: There was 1 hospital death (4.3%) due to cerebral embolism. Another patient died of pneumonia 1 year after surgery. Twenty-one patients (91%) survived during the follow-up period, but 1 patient (4.3%) suffered from paraplegia. The follow-up period ranged from 12 to 62 months (average, 34.3 +/- 15.2). There were no instances of aneurysmal rupture during the follow-up period. Postoperative serial computed tomography scans showed disappearance or significant shrinkage of the excluded aneurysmal space in 20 of 21 patients (95%), except for the one patient with endoluminal leakage., Conclusions: Transaortic endovascular stent-grafting was an effective alternative approach to treating distal aortic arch aneurysms or proximal descending aortic aneurysms. The excluded aneurysm disappeared or shrunk after successful placement of the stent-graft.

Extra-anatomic bypass is preferred for revascularization after removal of infected vascular grafts. The obturator canal technique has been used to bypass an infected field in the groin, although this method has not always been definitive because of several drawbacks. We present a unique method of extra-anatomic revascularization for use in such a situation. An autogenous graft is placed just below the sartorius muscle in the thigh and penetrates the iliacus muscle near the lateral end of the inguinal ligament. Limb loss and recurrent infection are prevented postoperatively. This retro-sartorius bypass technique may be a useful alternative to obturator bypass grafting in selected patients.

Background: Endovascular stent-grafting is an innovative procedure; we have developed a novel approach to treat distal arch aortic aneurysm through a small incision in the aortic arch., Methods: Eight patients with thoracic aortic aneurysms were treated with an endovascular stent-graft that was introduced into the thoracic aorta through a small incision in the aortic arch. Of these patients, 7 had distal arch aortic aneurysms, and 1 had chronic aortic dissection of Stanford type B. Four of these patients had received concomitant coronary artery bypass grafting, and 1 patient had undergone tricuspid valvular annuloplasty. The stent-graft was introduced into the distal arch aorta and descending aorta through a small incision in the aortic arch, under selective cerebral perfusion and hypothermic circulatory arrest., Results: The selective cerebral perfusion time ranged from 52 to 86 minutes (mean, 68 minutes) and the operating time from 289 to 422 minutes (mean, 318 minutes). There was no endoluminal leakage into the aneurysm. Seven patients survived and were discharged, but 1 patient suffered a cerebral infarction and died during the follow-up period., Conclusions: Placing an endovascular stent-graft through the aortic arch is an acceptable alternative treatment for distal arch aortic aneurysms.

Objective: Transesophageal echocardiography was applied to visualizing endovascular procedures during transaortic stent grafting for aneurysm and dissection at the distal arch, and the use of transesophageal echocardiography was evaluated., Methods: The 16 consecutive patients (13 with aneurysms and 3 with dissections) were examined. Transesophageal echocardiography was used for (1) determining graft size, (2) guiding placement of the catheter in the descending aorta at an appropriate position without intimal damage, (3) guiding graft tailoring with a balloon catheter, and (4) examining the results after the procedures., Results: Visualization was disturbed in one patient who had undergone a previous operation. The graft size was appropriate, except in one patient as a result of underestimation. Transesophageal echocardiography was helpful for navigating the graft placement and tailoring without intimal damage. We tried to keep a distance from the diaphragm of 9 cm and an attachment portion of 4 cm. In one patient the graft was placed too distally (7 cm from the diaphragm) to cover the thick atheromatous plaque with the graft. The patient had paraplegia. Transesophageal echocardiographic assessment of endoleak and thromboexclusion was identical to that of postoperative computed tomography or angiography, with a sensitivity of 100% (1/1) and a specificity of 100% (13/13). Leakage at the proximal suture and graft kinking were found in 3 patients. Successful thromboexclusion by transesophageal echocardiographic assessment (13 patients) was predictive of subsequent regression of aneurysm and dissection in the midterm follow-up period: there was complete and partial regression in 5 and 8 patients, respectively., Conclusion: Transesophageal echocardiography enables echocardiography-assisted operations with secure step-by-step endoluminal procedures and immediate intraoperative assessment, which is predictive of the postoperative results.

We report on 2 patients who underwent successful concomitant operation of coronary artery bypass grafting and stent grafting to descending thoracic aortic aneurysms. The device was inserted through a small linear incision on the anterior wall of the aortic arch. Intraoperative stent grafting to descending thoracic aortic aneurysms is an alternative therapeutic option for patients who require concomitant coronary artery bypass grafting and descending aortic replacement.

A 67-year-old man with severe discomfort was diagnosed with a rupture of the thoraco-abdominal aneurysm, a distal arch aneurysm and triple coronary artery disease. After emergency surgery for a thoracoabdominal aneurysm, a scheduled surgery for coronary artery bypass grafting and endoluminal stent-grafting for the distal arch aneurysm was performed simultaneously. A stent-graft was introduced into the descending aorta via a small incision on the arch aorta. Open endovascular stent-grafting via the arch aorta is an alternative for repairing a distal arch aneurysm with coronary artery bypass grafting.

We report the case of a 66-year-old man who had a descending thoracic aneurysm, diagnosed as aortitis syndrome. He subsequently underwent an aneurysmectomy under simultaneous sensory and motor spinal cord monitoring. Spinal cord ischemia was diagnosed during prosthetic replacement of the aneurysm by changes in evoked spinal cord potentials and motor evoked potentials from the lumbar spinal cord enlargement and 2 pairs of intercostal arteries were reconstructed at the level of T9 and 10. After surgery, the patient developed paraparesis below T10, but the resulting neurological deficits were overcome with postoperative rehabilitation. Simultaneous monitoring of evoked spinal cord potentials and motor evoked potentials were useful in evaluating spinal cord ischemia during aortic aneurysm surgery and in determing whether intercostal arteries should be reconstructed.

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.