A 72-year-old man with a thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery, Kommerell's diverticulum, and angina pectoris during follow-up for peripheral arterial disease was successfully treated surgically by two-staged operation. First, we performed total arch replacement using cardiopulmonary bypass, systemic hypothermia, selective cerebral perfusion, and coronary artery bypass grafting. Secondly, we performed replacement of the thoracoabdominal aortic aneurysm using a partial cardiopulmonary bypass. The postoperative course was uneventful. This is apparently the first case of repair for the thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery and Kommerell's diverticulum.

This report describes the results of endovascular stent graft repair for abdominal aortic aneurysms in comparison with conventional open surgery. Endovascular repair of abdominal aortic aneurysm was performed in 21 patients (SG group) and 69 patients were treated with conventional open surgery (OS group). The SG group had a higher preoperative risk than the OS group. The complete exclusion of the aneurysm at 2 weeks after the stent graft treatment was obtained in 16 out of 21 SG cases (76%). On the other hand, in the OS group, 68 of 69 cases underwent successful surgery (99%). The average amount of bleeding during the endovascular stent graft repair was 427ml and the average operation time was 242 minutes. Both blood loss and operation time were significantly lower compared to the OS group. The endovascular stent graft repair was less invasive in comparison with conventional open surgery. However, judging from the initial success rate, open surgery is more reliable than the endovascular stent graft repair. Our data suggested that the endovascular stent graft repair should be performed only in selected cases.

A patient with mutiple aneurysms of the thoracic aorta in Behçet's disease was treated with transluminally placed endovascular stent grafts. Stent graft devices composed of several units of self-expandable Z stents covered with ultra-thin woven Dacron were inserted through 18 Fr sheaths via the femoral arteries. The stent grafts were deployed successfully and blood flow into the aneurysms was reduced immediately and no blood endoleak was found on aortography. However minor endoleak due to migrations of the stent grafts was recognized in two distal descending aortic aneurysms twenty days after the operation. Extra stent grafts were inserted to interrupt the endoleak and finally all aneurysms were thrombosed without any endoleak. Former surgical replacement of the aorta due to aneurysms associated with vasculo-Behçet's disease often causes anastomotic leakage and pseudoaneurysms. The endoluminal stent graft treatment is a minimally invasive operation in comparison with former surgical operations, and is useful for aortic aeurysms especially for inflammatory aneurysms in Behçet's disease because it requires no anastomotis. However, improvement of the stent graft devices, including components of the delivery system such as the dilator, sheath and pushing rod, and the development of better devices, is required to reduce delivery failure and to make stent graft treatment more reliable.

Ten cases of pseudoaneurysms that developed after thoracic aortic surgery were treated with an endovascular technique using stent grafts for redo operations. All patients were treated under general anesthesia and the stent grafts were implanted through 18 Fr or 20 Fr sheath introducers via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in all patients and in 7 of 10 cases exclusion of the aneurysms with no endoleak was achieved within two weeks after the operation (initial success rate: 70%). Minor endoleak was found in 3 patients and one of those finally underwent conventional surgery because of stent graft migration 6 months after the stent graft repair. Two of ten patients died, 10 days and 18 weeks after the operation, due to hemoptysis, which had already been observed before the operation. Endovascular stent graft repair of pseudoaneurysms after thoracic aortic surgery is a minimally invasive operation in comparison with conventional redo surgery with extracorporeal circulation. These results and experiences suggest that stent graft repair can be a safe and useful redo treatment for pseudoaneurysms. However, careful long-term investigations are necessary to prove the value and effect of this endovascular treatment and a new strategy for cases with hemoptysis is required.

A high-risk abdominal aortic aneurysm patient with multiple complications was treated by a transluminally placed endovascular stent-graft. A tapered stent-graft composed of 3 units of self-expandable Z stents covered with ultra-thin woven Dacron was inserted through an 18 Fr sheath via the femoral artery. The stent-graft was deployed successfully, and endovascular exclusion of the abdominal aortic aneurysm was achieved. The endoluminal stent-graft treatment is an option for minimally invasive operation in comparison with conventional open surgery, and appears to be effective for aortic aneurysms in certain selected cases.

The elephant trunk procedure is used to close the false lumen of the distal aorta in the surgical treatment for aortic dissection. We examined the state of the false lumen thrombus and measured the diameter of the aortic dissection, using postoperative digital subtraction angiography and computed tomographic scanning. We performed the elephant trunk procedure in 24 cases in the period, between January 1995 to December 1999. Total aortic arch replacement was performed in Stanford type A dissection, and descending aorta replacement was performed in Stanford type B dissection. In all patients, thrombotic closure around the elephant trunk graft was confirmed. Thromboexclusion of the false lumen of the descending aorta was observed in 18 cases (75.0%). The secondary operation may be unnecessary, because there was a tendency towards reduction of the diameter of dissecting aorta. These data revealed that this procedure was effective. In 6 cases (25.0%), residual dissection was recognized in the thoracoabdominal aorta, but there was no case of expansion requiring further operation. Nevertheless, careful follow-up is necessary, because aneurysms could expand in the future.

We report on a rare case of Marfan syndrome with giant dissecting descending thoracic and abdominal aortic aneurysms associated with poor left ventricular function and severe mitral regurgitation. Before the anesthetic induction, a partial extra-corporeal circulation was established to prevent a collapse of the circulation. Descending aortic graft replacement and following abdominal aortic graft replacement were performed safely using the partial extra-corporeal circulation to relief the afterload for the severely deteriorated left ventricle with severe mitral regurgitation. Intra-aortic balloon pumping was also promptly used to assist the poor circulation in the postoperative period. Despite the admission to a specialized institute, he died from irreversible heart failure with a developing renal failure. Even for a difficult patient with Marfan syndrome with severe left ventricular dysfunction and mitral regurgitation, graft replacement was feasible with meticulous perioperative circulatory management using partial extra-corporeal circulation and intra-aortic balloon pumping. However, a prompt registration for heart transplantation and an aortic surgery concomitant with implantation of left ventricular assisted device should have been considered to save the patient.