Exposure of the surgical field and bleeding control are main problems of distal anastomosis during an operation for distal arch aneurysms. The open-stent technique and thoracic endovascular aortic repair (TEVAR) are useful techniques for the resolution of these problems. Recently, TEVAR has progressively expanded in the treatment of various complex thoracic aortic diseases. However, complications such as endoleaks and graft migrations have still remained an issue. Although some patients who have late distal endoleaks can be almost treated successfully with additional TEVAR, some of them cannot. We report 3 cases of graft replacement of descending aorta after open-stent technique due to stent migrations and endoleaks. All of them were previously performed by total arch replacement with open-stent technique for distal aortic arch aneurysms. The follow-up CT after the first operation revealed graft migrations and endoleaks. The open surgical repairs through left lateral thoracotomy were performed, followed by graft replacements. The stent grafts were easily clamped after the incision of the aneurysm. In 2 cases, grafts were directly anastomosed to the descending aorta after the removal of the stent. In 1 case, graft was extended with new graft and then anastomosed to the descending aorta. These procedures were technically successful ; there were no trouble to exfoliate aorta, to perform anastomosis and hemostasis, and neither patient developed major complications. These results indicate that open surgical repair of descending aorta could be one of the safety options for the treatment of endoleaks and stent migrations of thoracic aortic stent graft in the era of increasing endovascular therapy.

A 3-month-old girl of univentricular heart of left ventricular type with atresia of left atrioventricular valve (LAVV) and coarctation of the aorta (Co/AO) is presented. UCG and angiography revealed concordant AV connection with straddling RAVV with transposed great arteries [SDDT]. The following pressures (in mmHg) were noted on catheterization: RA mean 1 (a=3, v=1), LA mean 12 (a=17, v=14), LV 84/0/8, Ao 81/41, and PA 74/39. Patent foramen ovale (PFO) was restrictive and balloon atrioseptostomy was not feasible. Blalock-Hanlon atrial septectomy (8×6mm), subclavian flap aortoplasy (SFA) and pulmonary arterial banding were performed simultaneously under bilateral thoracotomy. Acute renal failure occurred after surgery and the girl required peritoneal dialysis for 5 days. At 6 months after surgery, girl is doing well. There will be a predictable fall in pulmonary vascular resistance after atrial septectomy and SFA with a ligation of PDA may result transient increase in systemic resistance. Therefore, atrial septectomy and SFA in conjunction with pulmonary arterial banding should be done simultaneously.

Fourteen cases (ranged 4 days to 5 months old, mean=40 days old) of coarctation of thoracic aorta underwent subclavian flap aortoplasty were between Jan. 1986 and Dec. 1990. Early postoperative course in these patients was reviewed retrospectively. In 9 cases of these patients, complex intracardiac anormalies co-existed (VSD in 7, ECD in one, single ventricle with MA in one). Preoperative pressure gradients between upper and lower extremities were 40±7mmHg and the gradients were significantly reduced after the repair of coarctation (8±4mmHg). Serum creatinine phosphokinase (CPK) increased postoperatively reaching peak levels by day 3 (12, 315 ±8, 462IU/l) and then gradually decreased. Gultamic oxaloacetic transaminase (GOT), glutamicpyruvic transanmiase (GPT), serum urea nitrogen (BUN) and serum creatinine (S-Cr) also increased postoperatively. When patients were divided into two group following the maximum CPK levels (group A: >4, 000; group B: <4, 000IU/l), the duration of mechanical ventilation (A: 117±21; B: 20±9hr), max. S-Cr levels (A: 2.16±0.64; B: 0.47±0.13mg/dl) and max. GPT (A: 323±127; B: 58±24IU/l) were significantly increased in group A. There was no significant correlation between these factors and postsurgical residual pressure gradients. An increase in these factors did not depend on the operation time, age, body weight and additional surgical procedures such as pulmonary arterial banding. These data suggest that the transient unbalanced blood distribution might exist even under no pressure gradients between upper and lower extremities. This might be important in the management of postoperative patients after repair of coarctation.

A 2-year-old girl who had been followed because of pulmonary valve stenosis since birth, underwent unsuccessful balloon valvuloplasty twice. The angiographic study showed thin cusps and remarkably thick and immobile filling defects in the main pulmonary artery, which indicated supravalvular PS or pulmonary valve dysplasia. Operation was done under conditions of a beating heart and total cardiopulmonary bypass. Pulmonary valve dysplasia was localized on the edge of all three cusps. After resection of the dysplastic lesion, the stenosis was released and slight regurgitation was observed by ultrasonography study.