Case 1
involved a 44-year-old woman with Marfan syndrome who underwent Bentall surgery and mitral valve replacement 33 years ago. Total arch and descending aorta replacements were also performed with a 28-mm 4 Branch-Hemashiled Platinum Woven Double Velour graft (INTERVASCULAR SAS, LaCiotat, France) for a dissected thoracic aortic aneurysm 17 years ago. Computed tomography angiography (CTA) revealed an extensive dissected TAAA (Fig. 1a); the maximum diameters the descending thoracic and abdominal aorta were 61 mm and 60 mm, respectively. The diameters of the bilateral external iliac arteries were < 6 mm each, and the Adamkiewicz artery could not be visualized. We scheduled a hybrid staged procedure with an initial open thoracoabdominal surgery followed by a TEVAR. Thoracoabdominal aortic replacement was performed using the following procedures: cerebrospinal fluid (CSF) drainage, perioperative monitoring of motor evoked potentials, partial extracorporeal circulation, selective visceral perfusion, and renal protection with cold lactated Ringer's solution. Mild hypothermia was instituted, with the minimum rectal temperature set at 34℃. Proximal aortic clamping was performed at the descending aorta just above the diaphragm, and the tubular graft was anastomosed to the descending aorta with a double-barrel graft. The distal anastomosis was the left external iliac artery for the TEVAR. We used 30-mm Triplex 1 Branch (Terumo, Tokyo, Japan), 26-mm Coselli Thoracoabdominal (Terumo, Tokyo, Japan), and 22 mm x 11 mm Bifurcated Hemashield Platinum Woven Bifurcated Double Velour Vascular graft (INTERVASCULAR SAS) grafts (Fig. 1b). The patient underwent postoperative reintubation and tracheotomy owing to sputum excretion difficulty. Forty-eight days after the initial operation, TEVAR was performed using 32–200 mm and 38–200 mm Zenith TX stent grafts (Cook Medical, Indiana, United States). Postoperative CTA showed no abnormal findings, (Fig. 1c) and no spinal cord injury (SCI) was observed. The patient was weaned from mechanical ventilation and discharged on the 126th postoperative day.
Case 2
involved a 65-year-old man who underwent TAR and proximal descending aorta replacement with a 26-mm UBE woven graft (Ube Industries, Tokyo, Japan) for type A aortic dissection 12 years ago. CTA revealed an extensive dissected TAAA; the maximum diameters of the descending thoracic and abdominal aortas were 55 mm and 45 mm, respectively. The Adamkiewicz artery was visualized as arising from the 12th intercostal artery. Thoracoabdominal replacement was performed similarly to that performed for the first patient. The descending aorta and Adamkiewicz artery were reconstructed using double-barrel anastomosis and two tubular grafts (24-mm thoracoabdominal J graft), respectively. TEVAR was subsequently performed with 31–200-mm and 31–200-mm Gore CTAG stent grafts (WL Gore, Newark, Delaware, United States) 19 days after the initial operation. No abnormal finding was observed with the postoperative CTA (Fig. 2a), and no SCI was occurred. The patient was discharged on the 34th postoperative day with no complications.
Case 3
involved an 81-year-old woman who underwent TAR with a 28-mm Triplex 4 Branch graft (Terumo, Tokyo, Japan) for an aortic arch aneurysm three months ago. The patient complained of back pain, and the CTA demonstrated a type B aortic dissection with an ulcer-like projection (ULP). The follow-up CTA indicated rapid dilatation of the ULP. The maximum diameters of the descending thoracic and abdominal aortas were 52 mm and 51 mm, respectively. The Adamkiewicz artery was not visualized. The thoracoabdominal aortic aneurysm was replaced with 28-mm thoracoabdominal J and 20 mm × 11 mm Hemashield Platinum Woven Bifurcated Double Velour Vascular graft (INTERVASCULAR SAS). Paraparesis was observed on the first postoperative day, but the patient recovered fully. No neurologic deficits were observed after the CSF drainage, and a mean blood pressure of > 85 mmHg was attained. TEVAR was performed with 31–200-mm Gore CTAG and 36-36-250-mm Relay plus (Bolton Medical, Sunrise, Florida, United States) grafts 30 days after the primary operation. The postoperative CT showed excellent graft patency without major endoleaks (Fig. 2b). The patient was transferred to another hospital on the 68th postoperative day.
Case 4
involved a 75-year-old man who underwent abdominal endovascular aortic repair (EVAR) for an abdominal aortic aneurysm. One month later, TAR with a frozen elephant trunk was performed with 26-mm Triplex 4 Branch (Terumo) and 35–60-mm J FROZENIX (Japan Lifeline, Tokyo, Japan) grafts for an aortic arch aneurysm (Fig. 3a-b). Eighteen months later, the patient complained of fever, and CT showed increased fluid around the stent graft, which indicated that the aneurysm had gradually dilated. The Adamkiewicz artery was visualized as arising from the 10th intercostal artery. A thoracoabdominal graft replacement was performed for the stent graft infection. The descending aorta was reconstructed at the level of the 12th intercostal artery (Fig. 2c). Anaphylactic shock from the contrast media occurred when the postoperative CT was performed. Considering the risk for SCI and anaphylaxis, we decided to monitor the descending aortic aneurysm closely. Six months later, the aneurysm ruptured, and we performed emergent TEVAR. However, acidemia and hyperpotassemia progressed, and the patient died on the same day.