A 67-year-old man suffered sudden chest pain. Computed tomography with contrast medium revealed dissection from the ascending aorta to the bilateral iliac arteries and hematoma around the left external iliac artery. Type A acute aortic dissection complicated with rupture of the left external iliac artery was diagnosed. Urgent endovascular repair (stent-graft implantation) was first performed for the arterial rupture more critical than the aortic dissection. On the next day after satisfactory hemostasis and hemodynamical stabilization, semi-urgent ascending aortic replacement was achieved, and the patient survived. Acute aortic dissection complicated with rupture of the aortic branch was extremely rare, and only 5 cases have been reported in the English literature.

We report a 49-year-old man with retrograde type A acute aortic dissection with patent false lumen in the ascending aorta. The patient successfully underwent urgent thoracic endovascular repair (TEVAR) to cover the primary entry on the onset (admission) day. The false lumen from the ascending aorta to the proximal descending thoracic aorta was completely thrombosed, gradually shrank, and finally disappeared. In conclusion, TEVAR for retrograde type A acute aortic dissection with a patent ascending false lumen is far less invasive than aortic replacement (with cardiopulmonary bypass, cardiac arrest, and circulatory arrest) and may be useful in selected patients with a primary entry located at least approximately 2 cm distal to the origin of the left subclavian artery.

Primary cardiac synovial sarcoma is extremely rare, and approximately100 cases had been reported according to a literature review in 2019. We herein reported a case of primary pericardial synovial sarcoma originating from the epicardium with cardiac tamponade. Pericardiocentesis, subsequent complete tumorectomy under cardiopulmonary bypass and cardiac arrest, and adjuvant chemoradiotherapy was performed, and the patient survived for 3 years with neither recurrence nor metastasis.

A 63-year-old female suddenly suffered right hemiplegia. Multiple cerebral infarctions in the nucleus basalis and the frontal and temporal lobes perfused by the left middle cerebral artery were diagnosed. A left atrial myxoma probably causing the cerebral infarctions was identified. The patient underwent anticoagulation therapy with heparin to prevent recurrent cerebral infarctions while waiting for surgical resection of the myxoma. Motor aphasia, however, occurred on the 8th day after the onset of the cerebral infarctions. Extensive hemorrhagic cerebral infarctions involving the left temporal and frontal lobes with a midline shift occurred, and accordingly the anticoagulation therapy was discontinued. After a 6-week interval from the hemorrhagic cerebral infarctions, the left atrial myxoma was successfully resected, and the patient was discharged from the hospital without any new neurological complications. Even if left atrial myxoma complicates extensive hemorrhagic cerebral infarctions, surgical resection may be safely performed allowing a sufficient interval. Anticoagulation therapy to prevent recurrent cerebral infarctions while waiting for surgery after cerebral infarctions should be avoided because of the risk of hemorrhagic cerebral infarctions, and early surgery should be considered.

A woman aged 87 underwent root replacement with a mechanical valve and ascending/arch replacement for annuloaortic ectasia with aortic regurgitation and ascending/arch aneurysm 10 years before and thoracic endovascular aortic repair for thoracic descending aneurysm 5 years before. She had been doing well but suffered sudden chest/back pain and bilateral lower-limb paralysis. Contrast-enhanced CT scans revealed filling defects initiating from the distal end of the thoracic stent graft and continuing to the bilateral femoral arteries. Massive thrombosis from the thoracic stent graft to the bilateral femoral arteries was diagnosed. The entire circumference of the thrombus was enhanced, and the thrombus was conceivable not attached to the aortic/arterial inner wall. Although the patient took warfarin orally for the replaced mechanical valve, anticoagulation with heparin was added. Her general condition promptly deteriorated and she died deceased 6 hours after the onset. Thrombosis continuing distally from the thoracic stent graft is extremely rare.

We report a case of semi-urgent infected endograft explanation following thoracic endovascular aortic repair (TEVAR) for distal anastomotic (DA) infectious pseudoaneurysm after total arch replacement (TAR). A 70-year-old male underwent TAR for distal arch saccular aneurysm 10 years before and open bifurcated graft replacement for an abdominal aortic aneurysm 5 years before. The patient was admitted 3 years before because of repeated pyrexia of 40°C. Contrast-enhanced CT scans revealed suspected vegetation and infectious pseudoaneurysm at the DA of the TAR, and semi-urgent TEVAR was performed on the next day. Antibiotic therapy was initiated for Staphylococcus capitis detected in a blood culture, and the patient was discharged after a negative blood culture. At this time, he was admitted owing to face and below-knee edema and dyspnea. Because a blood culture identified Methicillin-resistant Staphylococcus capitis and antibiotic therapy uncontrolled infection, we performed explanation of the infected endograft and distal end of the TAR graft and replacement of the descending thoracic aorta with a rifampicin-bonded graft under moderate hypothermic circulatory arrest with retrograde cerebral perfusion via the 4th intercostal posterolateral thoracotomy. Postoperative 6-week antibiotic therapy was continued and the patient was discharged in good condition after a negative blood culture on postoperative day 46.

A 77-year-old man suffered sudden chest oppression in driving. The patient had undergone aortic valve replacement with a mechanical valve for unknown valvular heart disease 17 years before. On arrival, the symptom was improved and hemodynamics were stable. Contrast-enhanced CT scans revealed remarkable pear-shaped dilatation of the aortic root (76 mm in maximum diameter), ascending aortic dissection, and extravasation from the posterior wall of the dissecting aorta with mediastinal hematoma compressing the left atrium. Ruptured type A acute aortic dissection with root ectasia (following aortic valve replacement) was diagnosed and urgent root and ascending aortic replacement was performed preserving the replaced mechanical valve. Initially, surgery not under hypothermic circulatory arrest but under normothermic aortic cross clamp was planned. Although sudden massive bleeding from the rupture site (dorsal to the ascending aorta) occurred during exposure of the ascending aorta (just proximal to the origin of the brachiocephalic artery), the procedure could be continued under bleeding control by the surgeon's fingers. The patient underwent re-sternotomy for hemostasis and undertook rehabilitation for discharge on the postoperative day 30. Mortality of ruptured type A acute aortic dissection is extremely high, and no surgical surviving case has been reported in the Japanese language.

A 66-year-old man with a history of pyogenic spondylitis a month before was presented with dyspnea. Severe aortic regurgitation due to infective endocarditis was suspected in transthoracic echocardiogram, and emergency surgery was conducted. The aortic valve with three cusps was markedly destroyed with vegetation. After resecting the cusps, there was a cavity just below the commissure between the left and noncoronary cusp (intervalvular fibrous trigon). In retrospective findings of intraoperative pre-cardiopulmonary bypass transesophageal echocardiogram, a left ventricular diverticulum with paroxysmal movement had been detected at the same place. The diverticulum was left untreated to shorten cardiac arrest time because of low left ventricular function, and aortic valve replacement alone was performed. Cardiopulmonary bypass was weaned with intra-aortic balloon pumping (IABP). Percutaneous cardiopulmonary support (PCPS) was initiated owing to hypotension in the intensive care unit. The PCPS and IABP were discontinued on postoperative day (POD) 5 and 6, respectively. Torsades de pointes and ventricular fibrillation occurred respectively 2 h after weaning the PCPS and on POD9, but recuperated to sinus rhythm within a minute. A 6-week course of antibiotic infusion was planned, and the patient is now undertaking rehabilitation on POD30 for discharge.

Leg malperfusion accompanied with type B acute aortic dissection (AAD) is reported to be an independent predictor for mortality. In such a case, though aortic replacement, extra anatomical arterial bypass or endovascular aortic repair (EVAR) can be selected, an appropriate treatment strategy has not been established yet. A 53-year-old woman was urgently hospitalized with sudden low back pain and right leg weakness, despite the right popliteal and anterior tibial arteries being palpable. Computed tomography (CT) revealed a type B AAD, and antihypertensive therapy was initiated. She complained of intermittent claudication during rehabilitation, and right leg ischemia with decreased ankle brachial pressure index (ABPI) was detected. The follow-up CT revealed the narrow true lumen of the right common iliac artery compressed by the thrombosed false lumen and the large entry of the aortic dissection in the terminal aorta. At the subacute phase of the aortic dissection, EVAR was performed. To expand the true lumen and exclude the entry, Y-shaped stent-grafts were implanted in the infra-renal aorta and the bilateral common iliac arteries. The postoperative course was uneventful. Postoperative ABPI returned to the normal range, and the intermittent claudication disappeared. In conclusion, EVAR should be considered in patients with type B AAD complicated with leg malperfusion.

Type B intramural hematoma (IMH) is not considered to be a life-threatening condition, and medical treatment is the first treatment choice. We report 2 cases of ruptured type B intramural hematoma. Total arch replacement was performed via median sternotomy, which is not a common surgical strategy for type B dissection. Case 1 : a 77-year-old woman was transferred to our hospital with chest and back pain. CT revealed type B IMH with a large hematoma in the anterior mediastinum. She underwent total arch replacement, but she died of respiratory failure on the 167th postoperative day. Case 2 : a 60-year-old man was transferred to our hospital with chest and back pain. CT revealed a type B IMH with a large hematoma on the anterior side of the arch. He underwent total arch replacement, but died of sepsis on the 13th postoperative day. We had 2 rare cases of ruptured type B IMH. In both cases, postoperative courses were problematic. However, median sternotomy could be an approach for ruptured type B dissection in some cases.