From the surgical stand point of view we have classified 129 patients with aortic dissections, of which anatomic variations were clearly identified. In addition to the DeBakey's nomenclature, we newly employed two groups, aortic arch type and abdominal aortic type. Futhermore, each type was divided into subgroups. This report provides practical and suitable operative approaches according to anatomic variations of the aortic dissecting aneurysms. 1. Twenty-one patients had type I dissections. Thirteen of 21 (62%) were combined with aortic valve regurgitations. 2. Ten patients had type II dissections. Eight of 10 (80%) showed aortic valve regurgitation. This type was further divided into three subgroups. 3. Eighty patients had type III dissections, consisting of 18 type III a and 62 type III b dissections. The type III a dissection included all the cases in which dissections did not involve major branches of the abdominal aorta. Retrograde dissections to the proximal ascending aorta were found in eight patients out of 80 (10%). 4. Twelve patients had aortic arch type dissections. This group was divided into two subgroups, according to the extent of the aortic dissection. 5. Six patients had abdominal aortic type dissections. This group was also subdivided into two. 6. On the basis of the types of dissections outlined above, the most suitable radical operative procedure was selectively proposed in each case.

Two hundred fourteen cases treated surgically for aortic aneurysms between Jan. 1986 and Dec. 1991 at our hospital. Among them, 15 cases (7.0%) had multiple aortic aneurysms. In 10 cases, aneurysms were resected completely: 9 simultaneously (one-stage operation) and 1 separately (two-stage operation), although in 5 cases there remained another aneurysm left even after operation. In all cases who had one-stage operation, the combination of sites of aneurysms were descending thoracic aorta and infra-renal abdominal aorta. Temporary bypass (n=4), centrifugal pump (n=4) or cardiopulmonary bypass (n=1) were employed as supportive methods during aortic cross-clamp. There were neither operative nor late death in one-stage operation group, although one patient died due to rupture residual aneurysm 1.2 years after the first operation. In these patients, vascular disease are expected to be present systemically, so that operative method should be determined carefully under consideration of poor general condition and another risk factors. We recommend, however, that simultaneous one-stage operation for multiple aortic aneurysm might be safe and fully acceptable procedure, especially in case of those whose aneurysms exist in descending thoracic and infra-renal abdominal aorta.

We report two cases of patch reconstruction for distal arch aneurysms. Supportive measures during operation included selective cerebral perfusion for brain protection and cardioplegic arrest for heart protection. During operation the whole body except for the heart was cooled down to 25°C, and only the heart was perfused at 36°C and kept beating. Both aneurysms were saccular, and after the resection of the aneurysm the defect of the aortic wall was reconstructed with woven double velour patches. The relationship between the pressure and the flow during coronary perfusion is not clear, but we thought the above measures should be taken when operating on distal arch aneurysm.

A 70-year-old man was found to have aortic regurgitation and underwent aortic valve replacement. About 10 minutes after disconnection from the cardiopulmonary bypass, cardiac arrest occurred suddenly and the bypass was immediately resumed. At this point, a Stanford type A aortic dissection was detected by transesophageal echocardiography, and the orifice of the left coronary artery was considered to be occluded by invasion of a hematoma. Although ascending aortic replacement with a prosthesis was performed under hypothermic circulatory arrest with selective cerebral perfusion, the heart did not resume vigorous beating. Therefore, saphenous vain graftings to the left anterior descending artery and the right coronary artery were performed. Finally, the patient could be weaned from the cardiopulmonary bypass. On postoperative digital subtraction angiography, neither occlusion nor stenosis in both coronary arteries was observed. We conclude that it would be considered to perform coronary artery bypass graftings in this particular condition.

A 61 y. o. male was admitted as a diagnosis of Stanford type A dissecting aortic aneurysm 6 day after the occurrence. An urgent operation was performed next day and the ascending aorta was replaced. Oral intake was initiated after uneventful postoperative 6 day-period. However, paralytic ileus became obvious associated with spiked fever over 38°C. Second trial after the suspension of oral intake also failed in the same result and turned out sepsis caused by Enterococcus faecium. The angiogram revealed the intact celiac axis and superior mesenteric artery (SMA), and the remarkably narrowed true lumen of the aorta. Although the clinical symptom was not typical, we thought that the ileus was induced by abdominal angina. At 78th postoperative day the fenestration of the abdominal aorta and the bypass grafting with saphenous vein between SMA and the abdominal aorta were performed. The symptom and sign of ileus subsided after the operation.

A 76-year-old man developed dysphagia and esophageal stenosis was diagnosed. A computed tomographic scan of the chest demonstrated a large aneurysm of the distal aortic arch. The patient had undergone left thoracoplasty 45 years previously for the treatment of lung tuberculosis, then the aortic arch with the aneurysm was displaced backward because of the narrowed upper thoracic cavity and the esophagus was sandwiched between the aortic arch and the spine. The patient was thought to be in danger of developing an aortoesophageal fistula, so an emergency operation was performed in spite of his age and general condition. He was successfully treated with graft replacement including reconstruction of three arch vessels and his severe dysphagia improved.

A 69-year-old woman, who had undergone mitral valve replacement, developed acute congestive heart failure and was transferred to our institution. Cineradiography demonstrated that two leaflets of the St. Jude Medical valve were stuck in a closed position. Emergency redo mitral valve replacement was performed with a CarboMedics valve. Postoperative hematological studies yielded a diagnosis of antiphospholipid syndrome. Although postoperative anticoagulant therapy was performed more carefully than usual, the prosthesis became stuck again. Therefore, a third operation was performed using a tissue prosthesis. We concluded that mitral valve plasty should be a first option for patients with antiphospholipid syndrome undergoing mitral valve surgery. Should prosthetic valve replacement be required, a tissue prosthesis would be best.

A 63-year-old man developed acute congestive heart failure with orthopnea and was transferred to our institution. Aortography and transesophageal echocardiography demonstrated that the aortic valve was congenitally quadricuspid. In preoperative coronary angiography, the left anterior descending artery and the circumflex artery arose from the same orifice of the right coronary artery. So far as we know, quadricuspid aortic valve associated with a single coronary ostium is an extremely rare congenital cardiac anomaly combination. During aortic valve replacement for this particular case, antegrade cardioplegia including a selective coronary perfusion was considered unreliable, thus continuous retrograde blood cardioplegia was employed for intraoperative myocardial protection.

Endoventricular circular patch plasty was performed in a 42-year-old man, with a postinfarction akinetic aneurysm. The case was complicated with severe congestive heart failure, marked pulmonary hypertension (70% of systemic pressure) and sustained ventricular tachycardia. Cardiac catheterization data revealed low ejection fraction (20%), high pulmonary capillary wedge pressure (33mmHg) and high pulmonary arterial pressure (70/33mmHg), associated with enlarged end diastolic volume index (142ml/m²). After the operation, contractile and volumetric improvements were observed, however the severe pulmonary hypertension remained without any improvement. Disappearance of life-threatening arrhythmia allowed his discharge from the hospital, but unsatisfactory hemodynamic data, except for improved ejection fraction to 49%, turned our attention to patient selection and alternative treatment (cardiac transplantation) for such a severe case.

Essential thrombocythemia is a rare disease belonging to the group of chronic myeloproliferative disorders. It displays both thrombogenic and bleeding tendencies due to increased platelet counts, as well as dysfunction. Aortic valve replacement with a 23mm Carpentier-Edwards bioprosthesis was performed for a 74-year-old man with aortic stenosis associated with essential thrombocythemia. No pre-treatment was performed before surgery, though the platelet count was 80×10⁴/μl. During the surgery, activated coagulation time was kept over 400 sec with heparin. There was no difficulty with hemostasis. Aspirin and warfarin were used as antiplatelet and anticoagulant agents after surgery, so the thrombin test results were controlled at around 30%. Since the platelet count reached 130×10⁴/μl, hydroxyurea as chemotherapy was given to suppress the platelet count below 100×10⁴/μl. The operation was completed without major problems and the postoperative course was uneventful. This patient remains in good condition.