胸腹部大動脈人工血管置換術中に逆行性解離，近位下行大動脈破裂をきたしエコーガイド下にステントグラフト内挿術を追加し救命しえた1例

Successful Echo-guided Deployment of Stent Graft for Intraoperative Retrograde Aortic Dissection and Rupture；Report of a Case

はじめに　心大血管手術中の急性大動脈解離はカニューレ挿入，遮断を契機に生じ，ただちに対処を要し，処置を施しても救命できない場合がある．本例はB型解離慢性期に胸腹部領域の瘤拡大に対し人工血管置換を施行した．術中に逆行性解離を生じ，近位下行大動脈で偽腔が破裂した．縫合・圧迫で仮止血を行い，ステントグラフト（SG）を内挿し完全な止血を得た．透視装置がない手術室でエコーガイド下にSGの位置決めと展開を行い，良好な結果を得たので報告する．

We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echo-guided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography （TEE） showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography （CT） showed good positioning and dilatation of the stent-graft and the perfect reverse remodeling of thoracic aorta.