The patient was a 50-year-old man who had undergone ascending aortic replacement and coronary artery bypass grafting at another hospital for acute type A aortic dissection 4 years before. He was diagnosed with hemolytic anemia 1 year after surgery for his progressive anemia and high serum lactate dehydrogenase level. He was referred to our hospital because frequent transfusion was required. A computed tomography showed severe kinking of the graft (110°), which we considered to be the cause of hemolysis. Peak pressure gradient was 60 mmHg. To remove the cause of hemolysis and to precipitate thrombosis of the residual false lumen, we performed re-ascending aortic replacement and total arch replacement with a frozen elephant trunk. The postoperative course was uneventful and hemolysis resolved soon after the operation. Surgeons should be aware that severe kinking of a Dacron graft can be a cause of hemolysis.

A 75-year-old man was referred to our hospital with a chief complaint of sudden back pain and fever. Enhanced CT showed a Kommerell diverticulum (KD) with right aortic arch and aberrant left subclavian artery (ALSA). It also showed type B aortic dissection with a closed false lumen and the horizontal diameter of the KD was 73 mm. We decided on elective surgery because the size of the KD was so large ; he also had aortic dissection and difficulty in swallowing due to compression of the esophagus. We avoided thoracotomy because it was challenging to approach to the KD and reconstruct the ALSA in situ. There also was the risk of injury to organs around the KD especially the esophagus and trachea via thoracotomy. Therefore, we performed an elective one-stage operation comprising total arch replacement (TAR) and frozen elephant trunk (FET) through median sternotomy followed by thoracic endovascular aortic repair (TEVAR). We could perform the operation safely with a good field of view. This strategy did not need a thoracotomy or in situ reconstruction of the ALSA. The post-operative course was uneventful and he was discharged 18 days after the operation. A CT scan 6 months after the operation showed size reduction of the thrombosed KD with no residual leakage of the stent graft. This hybrid method is one effective option for a KD with right aortic arch and ALSA. We report a successful one-stage hybrid operation for KD with some literature review.

The patient in this case was a boy aged 2 years and 9 months. The patient was transferred to our hospital with ductal shock, and bilateral pulmonary artery banding was performed on the 9th day after the diagnosis of interruption of the aortic arch, ventricular septal defect, subaortic stenosis, and bicuspid aortic valve. Left ventricular outflow tract stenosis due to aortic annulus diameter and subaortic stenosis after repair was suspected. Damus-Kaye-Stansel (DKS) anastomosis, extended aortic arch anastomosis, and a right modified Blalock-Taussig operation were performed. Preoperative examination of the intracardiac repair showed growth of the aortic annulus and confirmed that biventricular repair was possible after DKS take-down. The patient's native aortic and pulmonary valves were preserved, and an intracardiac repair was performed without using an extracardiac conduit. The postoperative course was uneventful, and the patient is currently in a good condition at the age of 6 years. Three and a half years after surgical intervention, echocardiography and cardiac catheterization showed improvement of subaortic stenosis and enlargement of the aortic annulus. Our findings indicate that the most appropriate surgical procedure can be selected by detailed examination of the preoperative condition at each stage of the staged operation.