The retroperitoneal approach for abdominal aortic aneurysm (AAA) has been used to reduce the risk of postoperative ileus and respiratory failure. This technique is usually used in patients with non-ruptured infrarenal AAA because it has been considered to be more time consuming to approach the aorta than the normal transabdominal approach. However, we may not have sufficient information if the aneurysm is confined to the infrarenal abdominal aorta in a ruptured case. In such a situation, the retroperitoneal approach might be better than the transabdominal approach because an aortic clamp can easily be applied to the suprarenal aorta. We report three cases of ruptured AAA treated successfully by the retroperitoneal approach.

A 48-year old man consulted a doctor at a nearby medical clinic due to dyspnea and increased body mass which he began to experience in October, 2011. Further evaluation revealed the presence of three-vessel severe coronary artery disease, poor left ventricular function, and mitral valve regurgitation. Transthoracic echocardiography showed anterior wall asynergy and left ventricular enlargement. Reconstruction of the left ventricle was contemplated during the preoperative evaluation. The patient underwent hemodialysis for chronic renal failure prior to admission. Generally, delayed gadolinium-enhanced MRI is used for cardiac viability assessment. However, gadolinium is contraindicated in a patient with chronic renal failure owing to the risk of development of nephrogenic systemic fibrosis. Thus, gadolinium-enhanced MRI is contraindicated in the patient. Instead, we used fluorodeoxyglucose-positron emission tomography (FDG-PET) computed tomography (CT) to assess myocardial viability. Consequently, viability was assessed except for a part of the apical electrode in the left anterior descending artery territory. Subsequently, revascularization and mitral valve annuloplasty with coronary artery bypass grafting of five vessels were performed in January, 2012 without left ventricular reconstruction. A left ventricular assist device was used postoperatively, from which he was later weaned. The outcome was good because post-operative left ventriculography revealed improvement in left ventricular wall motion. This case is presented including bibliographical comments on the effectiveness of FDG PET-CT for assessment of myocardial viability.

Purpose : The aim of this study is to evaluate the outcome of aortic valve replacement (AVR) with ascending aorta grafting under hypothermic circulatory arrest for patients with shaggy/calcified ascending aorta based on preoperative and intraoperative assessment of ascending aorta. Methods : From April 2010 to July 2019, 133 patients with aortic stenosis underwent AVR. Based on preoperative computed tomography and intraoperative epi aortic ultrasound, 121 patients were able to have their aorta clamped (C-AVR), while clamping was not possible for 12 patients due to shaggy/calcified in the ascending aorta (Asc-AVR). In Asc-AVR, ascending aorta was replaced to the vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion followed by AVR. Results : Although operative time and cardiopulmonary bypass time were prolonged and blood transfusion volume was significantly high in Asc-AVR, there were no significant differences in postoperative complications. Although postoperative MRI revealed two silent strokes, no symptomatic neurologic complications occurred in Asc-AVR. Five-year survival rates between groups were comparable (64.2% in Asc-AVR vs. 79.9% in C-AVR, p=0.420). Replacement of ascending aorta was not a risk factor of late death. Conclusion : AVR with ascending aorta grafting under hypothermic circulatory arrest based on preoperative and intraoperative assessment of ascending aorta is an acceptable method for patients with shaggy/calcified aorta.