A 61-year-old man underwent thoracic aortic graft replacement and abdominal aortic graft replacement because of a dissecting aneurysm. He presented with a ruptured residual dissecting thoraco-abdominal aortic aneurysm and underwent emergency thoraco-abdominal aortic graft replacement in February 2007. An inverted bifurcated graft was fashioned by cutting one of the two graft legs and creating an elliptical patch, like a cobra-head. In order to prevent paraplegia after the operation, it was necessary to shorten the duration of spinal cord ischemia. Once the elliptical patch was sutured to the orifices of the internal costal arteries with running sutures, selective intercostal arterial perfusion was initiated by using a cardiopulmonary bypass. After the operation, he did not suffer paraplegia.

We describe a 77-year-old woman with severe aortic stenosis, porcelain aorta and coronary artery disease, who underwent apicoaortic bypass with coronary artery bypass grafting. The patient, who had a history of aortitis syndrome had dyspnea. Cardiac echocardiography showed severe aortic valve stenosis (aortic valve pressure gradient (max/mean) = 115/74.4 mmHg, aortic valve area = 0.48 cm²). Coronary angiography showed severe stenosis of right coronary artery orifice (#1.90%) . Computed tomography showed severe calcification of the thoracic aorta and surgical manipulation for ascending aorta was impossible. We did not perform ordinary aortic valve replacement. Instead, apicoaortic bypass with coronary artery bypass grafting was performed. We approached by a left anterolateral thoracotomy at the 6th intercostal level. Apicoaortic valved conduit (valved graft : Edwards Prima Plus Stentless Porcine Bioprosthesis 19 mm + UBE woven graft 16 mm) was implanted. Saphenous vein graft was harvested and coronary bypass grafting (valved conduit-#4AV) was performed in the same operative field. Postoperative cine MRI showed that most of the cardiac stroke volume flowed through the conduit (44.4 ml/beat, 92.3%), with the flow via the aortic valve accounting for 3.69 ml/beat, 7.7%. Postoperative enhanced CT showed that the coronary artery bypass graft was patent. Apicoaortic bypass is a good surgical option for aortic stenosis with severe calcification aorta and coronary artery bypass grafting can also be performed in the same view.