Case
A 50-year-old woman presented with shortness of breath on
exertion. She had undergone total aortic arch replacement for Stanford
type A aortic dissection 17 years previously. She had been taking
prednisolone (7.5 mg) for SLE since she was 18 years old. Transthoracic
echocardiography showed left ventricular diastolic and systolic
diameters of 52 and 41 mm, respectively, left ventricular ejection
fraction of 42.5%, and mild aortic regurgitation. Echocardiography
revealed a large ascending aortic aneurysm compressing the right atrium.
Computed tomography showed the 63-mm ascending aorta near the proximal
anastomosis site compressing the superior vena cava and right atrium
(Fig. 1) and a 53-mm thoracoabdominal aneurysm (TAA) and a 38-mm
abdominal aortic aneurysm (AAA). Cardiac catheterization showed chronic
total occlusion of the left anterior descending (LAD) branch. The
patient underwent urgent surgery for ascending aortic aneurysm and LAD
occlusion.
Cardiopulmonary bypass (CPB) was initiated via right axillary and right
femoral artery perfusion, with inferior vena cava drainage through the
right femoral vein. Superior vena cava drainage was performed via median
sternotomy and CPB was established. The harvested great saphenous vein
was anastomosed to the LAD during systemic cooling to a bladder
temperature of 23°C. After circulatory arrest, the aneurysmal aortic
wall was incised. The artificial blood distal to the aneurysm was
clamped and circulation was resumed. Cardioplegic solution was infused
from the coronary ostium and anastomosed graft to achieve cardiac
arrest. Ascending aortic replacement was performed using a 24-mm J-graft
(Japan Lifeline Co., Ltd., Tokyo, Japan). Proximal anastomosis was
performed at the sinotubular junction level. The saphenous vein graft
was anastomosed to the J-graft and the aorta was declamped. A 5-mm hole
on the right atrium that had been adherent to the aneurysm was found and
directly closed. The CPB weaning was uneventful and the duration of
surgery, CPB, cardiac arrest, and circulatory arrest were 494, 229, 113,
and 3 mins, respectively. There was no recurrence of ascending aortic
aneurysm 2 years postoperatively.
Microscopic examination revealed that the aneurysm was true because the
aneurysmal wall was composed of all three layers including tunica
intima, media, and externa and showed severe atherosclerotic changes.
The tunica intima thickened with the formation of atheroma. The smooth
muscles of tunica media decreased, and the elastic fibers were
disordered. Some elastic fibers ruptured, and fragmented fibers were
observed in the tunica media. (Fig. 2a, b).