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Purpose: We have introduced a new surgical approach for extended thoracic aortic repair, anterolateral thoracotomy with partial sternotomy (ALPS)., Description: The surgical approach to the chest was made via left anterolateral thoracotomy and lower median sternotomy through the third or fourth intercostal space. All cannulations (arterial, venous, venting, and cardioplegia) could be easily performed using a retractor in this approach., Evaluation: From November 2005 to December 2010, we performed surgical treatment in 12 patients by employing the ALPS approach for a complex, extended thoracic aortic diseases with different pathologies, i.e., arteriosclerotic aneurysms in 5, acute type B dissection in 5, and chronic type B dissection in 2 patients. One patient died in the hospital, and 1 had temporary spinal cord injury., Conclusion: The ALPS approach might become an alternative for a complex, extended thoracic aortic replacement.

We reported successful distal repair using the frozen elephant trunk technique to treat a mycotic aneurysm extending from the ascending aorta to the descending aorta. A blood culture sample was positive for Escherichia coli, and total arch replacement with a rifampicin-bonded graft covered the omental pedicle flap.

Objective: The aimed to describe the frozen elephant trunk (FET) technique and partial remodeling (PR) for acute type A aortic dissection (ATAAD), considering the long-term prognosis on the basis of our 13 years of experience., Methods: There were 80 consecutive patients (mean age: 66.4 years) with an FET and PR technique for ATAAD between September 1997 and February 2010. We indicated a PR for all 80 patients without dilatation of the sinuses and a FET for 20 patients with a distal entry in the descending aorta, 14 patients with a dilatation more than 4cm on the distal arch and 46 patients with a narrow true lumen younger than 70 years with a narrow true lumen. During moderate hypothermic circulation with selective cerebral perfusion and distal perfusion from the femoral artery, a stent graft (mean diameter: 27.7mm, mean length: 9.9mm, mean distal depth: thoracic vertebra (Th) 6.0th) was inserted through the transected proximal aortic arch. The plication of the sinotubular junction (N=42) or partial remodeling for right and/or non-coronary cusp (N=38) was performed after total arch replacement with a four-branched prosthesis., Results: Four patients died in hospital. Early morbidity included two (2.5%) strokes but no spinal cord injury. In long-term follow-up (mean 94.6 months), five patients died of non-aortic events and two re-operations (Bentall and stent grafting to the descending aorta) were required. No patients had patent false lumen on the stent graft and residual aortic regurgitation, according to late follow-up computed tomography (CT) and echogram. The 10-year survival was 75% and the overall 10-year re-operation free rate on the thoracic aorta was 95%., Conclusion: FET and modified PR techniques could be effective for improving the long-term outcome on the distal and proximal aorta in an ATAAD., (Crown Copyright © 2011. Published by Elsevier B.V. All rights reserved.)

Purpose: We describe the long-term efficacy of early entry closure for acute type B aortic dissection by open stent grafting based on long-term results and changes in the false lumen on enhanced computed tomography (CT)., Methods: We performed open stent grafting for acute type B aortic dissection in 28 28 patients between 1998 a 2008. They included 14 patients with complicated type B aortic dissection (11 patients with limb and/or visceral ischemia and 4 patients with impending rupture). Uncomplicated type B aortic dissection was present in 14 patients, including 4 patients with an ulcer-like projection and 10 patients who had stable dissection with a patent false lumen., Results: Two patients who had the ischemic type died within 30 days. Postoperative complications occurred in two patients, including one case of paraplegia and one of mediastinitis. Two more deaths occurred during a median follow-up period of 45 months (range 6-114 months), with one related to open stent-graft infection and one due to pneumonia. The overall survival rate 5 years after open stent grafting was 77%. According to follow-up by CT, the false lumen was completely thrombosed and obliterated in all 26 patients with stent grafts., Conclusion: Early entry closure for both complicated and uncomplicated acute type B aortic dissection with an open stent graft has an acceptable early outcome and provides a high aortic remodeling rate.

Objectives: This study describes the long-term safety and effectiveness of extended aortic arch replacement with the frozen elephant trunk technique from our 12 years of experience., Methods: Between September 1997 and September 2008, 156 patients (mean age 67.9 years) with different pathologies from the aortic arch to the extended descending aorta in 100 dissections (acute A/acute B/chronic B=66/26/8) and 56 thoracic arteriosclerotic aneurysms (TAAs) had the frozen elephant technique performed upon them. During moderate hypothermic circulation with selective cerebral perfusion, the stent graft was inserted through the transected proximal aortic arch with trans-oesophageal echo guidance., Results: Six patients (3.2%) (acute A/acute B/chronic B/TAA=3/2/0/1) died in hospital. Postoperative morbidity induced four (2.6%) strokes (acute A/acute B/chronic B/TAA=2/0/0/2) and three (2.0%) spinal injuries (paraplegia in two and transient paraparesis in one) (acute A/acute B/chronic B/TAA=0/0/1/2). In the long-term follow-up (mean 63.3 + or - 39.2 months, maximum 144 months) 16 patients died. The survival rate was 99.3%, 86.5% and 74.9% at 1, 5 and 10 years, respectively. An additional operation was performed in 15 (9.4%) (ascending aorta/aortic root/descending aorta/abdominal aorta=1/2/5/7) including three stent-graft-related events (2.1%), and the additional repair proved successful. A follow-up computed tomography (CT) image was available for 96.0% (143/149) of patients who survived longer than 12 months. The size of false lumen or aneurysm increased in four patients, was unchanged in 20 patients (14.0%), shrank in 66 (46.2%) and was completely obliterated in 55 (37.1%)., Conclusions: The frozen elephant technique could be an attractive treatment for extended aortic arch disease to the extended descending aorta for acute aortic dissection as well as arteriosclerotic aneurysm., (Crown Copyright 2010. Published by Elsevier B.V. All rights reserved.)

Objectives: The objective of this report is to elucidate the feasibility of the frozen elephant trunk technique as a one-stage operation for extensive arteriosclerotic aneurysms and to investigate the long-term durability and efficacy of this procedure from our 11 years of experience., Methods: The subjects were 58 consecutive patients who electively received the frozen elephant trunk technique for arteriosclerotic aneurysms involving the aortic arch and the descending aorta between September 1997 and September 2008. Concomitant procedures included 15 coronary artery bypass grafts, 2 aortic valve replacements, 1 aortic root replacement, and 3 maze procedures. The stent graft was delivered to the seventh thoracic vertebra level (Th7) in 22, Th8 in 26, Th9 in 8, and Th10 in 2 patients. Cerebrospinal fluid drainage was administered preoperatively in 10 (17.2%) patients., Results: Operative mortality within 30 days was 0 of 58. There was 1 in-hospital death. Perioperative morbidity included strokes and spinal cord injury in 2 (3.4%) patients each. During the mean follow-up period of 54.2 +/- 36.9 months, there were 9 (15.5%) late deaths, and 7 (12.1%) patients required additional intervention. The 8-year survival was 65.5%, the overall 8-year aortic event free survival was 72.8%, and the 8-year event free survival on the site of the stent graft was 94.8%. A follow-up computed tomographic image was available for 86.2% (50/58) of patients who survived longer than 6 months. The size of the aneurysm increased in 1 (2.0%) patient, was not changed in 6 (12.0%) patients, shrank in 34 (68.0%) patients, and was obliterated in 9 (18.0%) patients., Conclusions: The frozen elephant trunk for extensive aortic aneurysms had long-term durability and efficacy and might become the alternative treatment for extended aortic replacement., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To describe the fate of the false lumen remaining in the descending thoracic aorta after extensive primary repair of the thoracic aorta by the modified elephant trunk technique with a stent graft for acute type A aortic dissection, particularly the changes of the false lumen on enhanced CT scanning., Methods: The subjects were 65 consecutive patients who received arch replacement with an open stent graft for type A acute aortic dissection. CT scanning was performed at 1, 3, 12, 36, and 60 months postoperatively to detect thrombus formation, absorption of thrombus, and obliteration of the false lumen after its exclusion by the stent graft. The aorta was measured at four levels, which were the distal border of the stent graft, the middle and distal parts of the descending thoracic aorta, and the origin of the superior mesenteric artery., Results: Obliteration was recognized in all patients at the distal border of the stent graft and absorption of thrombus was seen in 90% at the middle of the descending thoracic aorta within 1 year after surgery. However, the false lumen remained patent at the superior mesenteric artery (SMA) level in 50% of the patients., Conclusions: In patients with acute type A aortic dissection, it is possible to perform extensive primary repair of the thoracic aorta with relative safety by stent grafting, and this method may reduce the necessity for further operations to manage a residual false lumen.