We performed a surgical correction on a 53-year-old male patient, who had suffered from Stanford type A aortic dissection. The thoracic aorta was dilated along its whole length. Under retrograde cerebral perfusion, the correction consisted of extended Cooley's hemiarch repair and the closure of the tear, which was an entry into the pseudolumen of the descending thoracic aorta. The postoperative course was uneventful except a temporary DIC due to extensive thrombosis of the pseudolumen of the descending thoracic aorta. We think that the second operation of the descending thoracic aorta is unneccesary. Although the staged operation is generally approved for broad Stanford type A aortic dissection, we succeeded in a clinically curative one-staged operation using extended Cooley's hemiarch repair only with a median sternotomy.

This report describes 5 patients in whom extensive graft replacement was performed using a combination of median sternotomy with antero- or postero-lateral thoracotomy: 3 of them received replacement from the ascending to the descending thoracic aorta through the transverse aortic arch, and 2 of them received replacement from the transverse aortic arch to the descending thoracic aorta. Four of the 5 patients had catastrophic pulmonary bleeding during surgery and died immediately after the surgery. Histological investigations on 3 of the 5 patients revealed the presence of bleeding in bilateral alveola; edema in the pulmonary parenchymal tissues; and heavy bleeding extensively in the lung which was especially intensive in the pulmonary hilum and caused necrosis of that region in one case. We presume that long periods of total heparinization (extracorporeal circulation time>240min) performed during lateral thoracotomy, were the most important cause of the pulmonary bleeding. Other factors that could cause pulmonary bleeding are (i) avoidance of use of a double lumen endotracheal tube, (ii) pulmonary congestion due to heart failure during surgery, and (iii) pulmonary injury caused by surgical manipulation. We therefore consider that extensive graft replacement of the thoracic aorta through lateral thoracotomy using a pump-oxygenator, is associated with a high risk of pulmonary bleeding when it takes longer than 240min, and it is essential to perform the graft replacement in the possible shortest time.