Magnetic resonance imaging was performed on ten patients (eight men and two women) after placement of a prosthetic ascending aortic graft. The patients ranged in age from 42 to 78 years (mean: 57 years) and the scans were obtained a mean of 24 months postoperatively (range: 3 to 50 months). Nine patients had a pathologic diagnosis of cystic medial necrosis and the remaining patient had atherosclerotic changes in the ascending aorta. Of the nine with cystic medial necrosis, three had acute dissection of the ascending aorta, three had aneurysmal dilatation of the ascending aorta ranging from 6 to 10 cm in diameter, and three had chronic ascending aortic dissection. The three patients with acute dissection all presented with acute aortic regurgitation and hemodynamic collapse and were operative emergencies. Hemodynamically signif­icant aortic regurgitation also was present in the aneurysm and chronic dissection groups. The one patient with atherosclerosis had an acute dissection without aortic valve involvement and had an aortic repair with a prosthetic intraluminal stent. All nine patients with cystic medial necrosis had insertion of a Bjork-Shiley valved conduit to replace the aortic valve and ascending aorta (Table 1).

A standard operative approach was used for all patients. A median sternotomy incision was made after exposure of a nondissected femoral artery for systemic perfusion followed by cannulation of sutured together in a side-to-side fashion.
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Table 1—Patient Characteristics

Patient

Age

Months

No.

Sex

Ы

Post-Surgery

Primary DX

AI

1

M

49

32

D

3 +

2

M

48

32

D

4 +

3

F

50

21

D

4 +

4

M

56

50

A

4 +

5

M

60

28

A

4 +

6

M

64

45

A

3 +

7

M

78

6

D

Not present

8

M

54

4

D

3 +

9

F

66

18

D

3 +

10

M

42

3

D

2 +

Completion of the distal anastomosis near the innominate artery again depended on the local anatomy. In those patients with an acute dissection, the distal graft was trimmed and sewn to the aorta directly if the tissues appeared suitable to hold sutures. If the dissection continued beyond the innominate artery or if the tissues appeared too thin to hold sutures, an intraluminal stent was placed and held in position with tapes tied over the outside of the aorta. In these instances, the tubular graft portion of the stent was sewn in an end-to-end fashion to the graft of the valved conduit.

Table 2—Operative Technique

Patient

Age

Proximal

Distal

No.

(yr)

Graft*

Graft

Technique

1

49

29B-S

Single composite

Sewn to aorta

2

48

25B-S

No.
24
stent

Graft-graft
anastomosis

3

50

25B-S

No.
23
stent

Graft-graft
anastomosis

4

56

31
B
-S

Single composite

Sewn to aorta

5

60

29B-S

No.
29
stent

Graft-graft
anastomosis

6

64

25
B
-S

Single composite

Sewn to aorta

7

78

34
Stent

No.
34
stent

Both ends stent

8

54

27
B-S

Single composite

Sewn to aorta

9

66

25
B-S

Single composite

Sewn to aorta

10

42

27
B-S

No.
24
stent

Graft-graft
anastomosis

In all the patients studied, the outer adventitial layer of the aneurysm or the dissection was trimmed and wrapped over the completed graft repair. This wrapped sac controlled the bleeding from suture holes or from the graft interstices until hemostasis was obtained (Table 2).
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The right atrium for venous return. Hypothermic (20°C) cardiopul­monary bypass was used with a crystalloid and albumin prime. Cold blood cardioplegia provided myocardial protection.