We assessed the late aortic reoperation after surgery for type A acute aortic dissection (AAAD). Subjects were 108 consecutive patients with AAAD who underwent surgery by routine aortic arch replacement using geratin-resorcin-formalin-glutaraldehyde (GRF) glue between January 1996 and December 2010. Seven of the 94 patients who were discharged after the initial repair of AAAD required reoperation for the residual aorta. Reoperations included 4 procedures on the distal aorta and 3 procedures on the proximal aorta (aortic root or ascending aorta) at a mean interval of 6.1±3.5 (0.9∼13.7) years after initial surgery. There were no hospital reoperation-related deaths. Freedom from reoperation was 96% and 89% at 5 and 10 years. In conclusion, the use of GRF glue may influence the risk of reoperation after surgery for AAAD, but our results showed that there were very few of such cases. Furthermore, routine aortic arch replacement for AAAD may reduce late aortic reoperations after surgery by eliminating possible risks of residual tear at the transverse arch.

In particular, pseudoaneurysms formed at suture lines often are injured during resternotomy. Between 1993 and 1997, 5 patients with large ascending aortic aneurysms eroding the sternum underwent graft replacement using profound hypothermic circulatory arrest. A VA bypass was established through the femoral artery and vein and the patients were cooled to achieve profound hypothermia. After total disappearance of EEG activity was confirmed, circulatory arrest was established and resternotomy was conducted. In 4 patients who had pseudoaneurysms at proximal suture lines, the aneurysms were injured during resternotomy, however the grafts above the aneurysms were clamped 5 to 10min after resternotomy and cardiopulmonary bypass resumed. Infected grafts were removed and replaced with new grafts in 4 cases and hemiarch repair was conducted in 1 case. There was 1 hospital death due to multiple organ failure. Four patients survived operations and were discharged without any deficit. The hypothermic circulatory arrest technique makes it easier to obtain a good operative field and to manage any rupture immediately than by the selective cerebral perfusion technique.

The internal thoracic artery (ITA) has been established as the preferred conduit for myocardial revascularization. Several reported improved late results of coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (BITAs). In our institute, BITAs have been used for CABG from 1993. Since 1995, the indications for use of BITAs were extended to high risk patients. Between January 1995 and December 1997, 119 patients received BITAs for coronary artery revascularization. Right ITAs were anastomosed to the left anterior descending arteries (65%), the diagonal branches (7%), the left circumflex arteries (12%) and the right coronary arteries (10%). In 8 patients (7%), free right ITAs were used to bypass between proximal and distal portions of the right coronary artery. The hospital mortality rate was 4.2%. Regarding hospital morbidity, there were 2 patients with sternal infection and 2 patients with LOS postoperatively. There was no reoperation for bleeding. No significant difference was observed in the rate of wound infection or rate of operation without blood transfusion between the patients having BITAs grafting and those having unilateral ITA or saphenous vein grafting only, during the same period. Diabetes mellitus, older age, feminine gender, reduced ejection fraction and urgent operation are known risk factors for CABG. Among patients with these factors, no significant difference was observed in hospital mortality rate between patients with BITAs grafting and those with unilateral ITA grafting. The operative results of CABG using BITAs were considered to be satisfactory.

In a series of 20 consecutive patients from 1970 through 1988, aortic arch aneurysms were treated with the aid of selective brain perfusion. In our institute, cerebral perfusion was carried out with individual roller pumps, when the femoral artery was used for body perfusion and the innominate (INA) or right axillary artery (RAX) and left common carotid artery (LCA) were used for brain perfusion. The flow rate was 6.4±0.6ml/kg/min to the INA, 7.4±1.7 to the RAX and 5.7±1.5 to the LCA. The operative deaths were accounted in 5 cases (25%), the post operative cerebral complication was observed in 1 case (5.9%). At present we prefer to make a purse-string suture and insert the cannulas to the INA or LCA without clamping these arteries. Currently we carried out the separated brain perfusion under moderate hypothermia (26∼28°C) with indivisual roller pumps, when we maintained the flow rate to the INA or RAX constant at 7ml/kg/min, the LCA at 5.

A 76-year-old man had increasing thoracic and abdominal aortic aneurysms. First, endovascular repair was performed on the thoracic descending aorta, but type Ib endoleak persisted due to severe aortic calcification. Additional treatment was planned since the maximum diameter of the thoracic and abdominal aortic aneurysms had increased to 75 and 70 mm, respectively. Due to the fact that aortic calcification was present from the aortic arch to the bilateral iliac arteries, which is sometimes referred to as porcelain aorta, conventional open thoracoabdominal aortic repair or hybrid repair using retrograde debranching seemed impossible. Therefore we performed antegrade visceral debranching from the ascending aorta followed by endovascular thoracoabdominal aortic repair successfully. For the thoracoabdominal aortic aneurysms which present difficulty in performing conventional open surgical repair or hybrid repair with retrograde debranching from the iliac artery. This technique can be an effective alternative strategy, but still needs further investigation, including its indications, due to the high surgical stress associated with the procedure.