全弓部置換術後にオープンステントグラフト狭窄をきたした右側大動脈弓

Open Stent Graft Stenosis after Total Arch Replacement for Acute Aortic Dissection in a Patient with Right-sided Aortic Arch

胸部大動脈疾患に対するオープンステントグラフト（OSG）法はKatoら1）によって最初に報告され，2014年1月にはJ Graft Openステントグラフト（JOSG）［日本ライフライン社，東京］が国内初のOSGとして承認された．Uchidaら2）によってその有用性が報告されている一方で，今日までにOSG法に特有な合併症の報告が少しずつ蓄積されている．われわれは，右側大動脈弓（RAA）の急性大動脈解離に対してJOSGを使用し，術後JOSGの狭窄をきたした症例を経験したので報告する．

We describe a patient with stenosis of an open stent graft during total arch replacement of a right-sided aortic arch. A 67-year-old man was transferred to our hospital with a diagnosis of acute type A （DeBakey type Ⅱ） aortic dissection. Computed tomography （CT） imaging revealed concomitant right-sided aortic arch （RAA） and Kommerell diverticulum at the descending thoracic aorta. Total arch replacement was performed using an open stent graft over the Kommerell diverticulum. While closing the sternum, blood pressure of the femoral artery dropped to a level much lower than that of radial artery. Transesophageal echocardiography revealed an apparently new intimal flap in the descending thoracic aorta. Therefore, an axilla-femoral artery bypass and a femoro-femoral artery crossover bypass were performed to improve malperfusion of the visceral organs and lower extremities. CT imaging immediately after these procedures revealed stenosis at the non-stented portion of the open stent graft, which was located at the steep-angled site of the RAA. The pressure gradient between the upper and lower extremities was around 100 mmHg on the day of surgery, but it disappeared on postoperative day 4. Improved graft stenosis was confirmed by CT before discharge.