Ann Vasc Dis Vol. 8, No. 1; 2015; pp 49–51 ©2015 Annals of Vascular Diseases
Online February 16, 2015 doi:10.3400/avd.cr.14-00122
Case Report
Ascending Aortic False Aneurysm Formation Associated with Rupture of Acute Type A Aortic Dissection Yoshitaka Yamane, MD, Shogo Mukai, MD, Hironobu Morimoto, MD, and Shuhei Okubo, MD
A 63-year-old man with ruptured acute type A aortic dissection was referred to our hospital. Computed tomography showed a false aneurysm arising from the false lumen located beside the ascending aorta. His hemodynamic status was stable inspite of the ruptured acute aortic dissection. We consider that the containment of the false aneurysm by thin mediastinal structures prevented worsening of his hemodynamic status, and this is extremely rare.
Keywords: aneurysm, aortic dissection, aortic operation
Introduction False aneurysm of the ascending aorta unrelated to trauma, or previous aortic or cardiac surgery is extremely rare. The false aneurysm is surrounded and controlled by closely-related thin mediastinal structures. When the pressure in the false aneurysm exceeds the maximally tolerated tension of the surrounding tissue, fatal rupture occurs.1) In particular, a false aneurysm that forms rapidly has a thin and fragile wall, and emergent surgery is needed. We report a rare case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection.
Case Report A 63-year-old man with a history of hypertension was admitted to another hospital because he had sudden syncope. Computed tomography (CT) revealed acute type A aortic dissection, and he was referred to our hospital for Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama, Hiroshima, Japan Received: October 19, 2014; Accepted: December 18, 2014 Corresponding author: Yoshitaka Yamane, MD. Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, 2-39 Midorimachi, Fukuyama, Hiroshima 720-0804, Japan Tel: +81-84-931-1111, Fax: +81-84-925-9650 E-mail: [email protected]
Annals of Vascular Diseases Vol. 8, No. 1 (2015)
05_10_cr_00122_Yamane.indd 49
surgery. When he arrived at our hospital, his hemodynamic status was stable, his blood pressure was 110/78 mmHg and his heart rate was 78 beats/min (regular). CT films from the referring hospital showed pericardial effusion and a ruptured type A aortic dissection with a primary entry tear in the distal aortic arch (Fig. 1A). In addition, there was a false aneurysm arising from the false lumen that was enhanced in the early phase (Fig. 1B). The false aneurysm was located beside the ascending aorta and expanding into the transverse sinus (Fig. 1C, D). We performed an emergency operation. After median sternotomy, the pericardial cavity was found to be filled with old blood, and there was no pericardial adhesion. Total cardiopulmonary bypass was initiated with retrograde perfusion through the femoral artery and bicaval venous drainage with left ventricular venting. After antegrade cold blood cardioplegia was selectively administered, cardiac arrest was obtained. However we could not find the tear of adventitia which had caused the false aneurysm, we could identify the false aneurysm surrounded by connective tissue and hematoma. We thought that the tear of adventitia was located in the ascending aorta because adventitia of the aortic root was not ruptured. The transected proximal stump of the ascending aorta was reconstructed with both inner and outer Teflon felt. He was cooled to 28°C, the ascending aorta was opened and selective antegrade cerebral perfusion was established. We performed total arch replacement using Dacron graft. Thoracic endovascular aortic repair was performed to close the primary entry 12 days after the surgery. The false aneurysm was not seen on the postoperative CT (Fig. 2), and his postoperative course was satisfactory.
Discussion False aneurysm is a rare and life threatening complication that occurs in 0.5% of all cardiac surgical cases.2) False aneurysm of the thoracic aorta results from transmural disruption of the aortic wall and is contained by the surrounding mediastinal structures. When the pressure in the 49
2015/03/12 11:48
Yamane Y, et al.
(A)
(B) FL TL FA
FL TL
(C)
PA
(D) FL PA TL FA FL TL
FA
Fig. 1 Preoperative computed tomography (CT). Preoperative CT showed type A aortic dissection with a primary entry tear in the distal aortic arch (A). A false aneurysm, which was enhanced in early phase, was located beside the ascending aorta arising from the false lumen (B: white arrow) and expanding into the transverse sinus (C, D). FA: false aneurysm; TL: true lumen; FL: false lumen; PA: pulmonary artery.
Fig. 2 Postoperative computed tomography angiography. The false aneurysm was not seen.
false aneurysm exceeds the maximally tolerated wall tension of the surrounding tissue, fatal rupture occurs and emergent treatment is needed. Various mechanisms for the formation of false aneurysm have been reported, including infection, poor anastomotic technique during surgery and intrinsic aortic wall disease.1–2) However, 50
05_10_cr_00122_Yamane.indd 50
there are few reports of false aneurysm formation associated with acute aortic dissection. In our case, the patient’s hemodynamic status was stable when he arrived at our hospital, in spite of the ruptured acute aortic dissection. Although the false lumen of the dissected ascending aorta penetrated into the pericardial cavity, it was contained by thin mediastinal structures within the transverse sinus, and this resulted in the formation of a false aneurysm and prevention of further bleeding. This is the reason for the patient’s stable hemodynamics status. Pretre, et al. reviewed a series of case with blunt injury of the ascending aorta. They reported that 14 of 21 patients who could be treated surgically presented mainly with false aneurysm of the ascending aorta and appeared in stable condition.3) When the adventitia of the dissected aorta developed a small tear, the blood pressure fell suddenly, resulting in the formation of a false aneurysm contained by thin connective tissue surrounding the ascending aorta. In our case, we believe that the false aneurysm was formed by the same mechanism as when the patient experienced syncope. In addition, we believe there is another reason a false aneurysm was formed. The ascending aorta had retrograde dissection, and the blood pressure at the rupture Annals of Vascular Diseases Vol. 8, No. 1 (2015)
2015/03/12 11:48
Ascending Aortic False Anuerysm
site from the false lumen was lower than the actual aortic blood pressure. In our case, the patient might have had favorable conditions for the formation of a false aneurysm. We sometimes experience false aneurysm of the arch or descending aorta. However, false aneurysm formation associated with a ruptured ascending aorta and a stable hemodynamic condition is extremely rare. We believe that the patient’s hemodynamic stability was due not only to hemostasis, but also involved the process of re-rupture of the dissected aorta.
Conclusion Formation of a false aneurysm may prevent further bleeding, allowing the patient to maintain a stable hemodynamic status and undergo surgery. However, the false aneurysm may rupture again, since it forms rapidly, and has a thin
Annals of Vascular Diseases Vol. 8, No. 1 (2015)
05_10_cr_00122_Yamane.indd 51
and fragile wall. Therefore, surgery should be performed as swiftly as possible.
Disclosure Statement The authors have no conflicts of interest to declare.
References 1) Malvindi PG, van Putte BP, Heijmen RH, et al. Reoperations for aortic false aneurysms after cardiac surgery. Ann Thorac Surg 2010; 90: 1437-43. 2) Atik FA, Navia JL, Svensson LG, et al. Surgical treatment of pseudoaneurysm of the thoracic aorta. J Thorac Cardiovasc Surg 2006; 132: 379-85. 3) Prêtre R, LaHarpe R, Cheretakis A, et al. Blunt injury to the ascending aorta: three patterns of presentation. Surgery 1996; 119: 603-10.
51
2015/03/12 11:48
Online February 16, 2015 doi:10.3400/avd.cr.14-00122
Case Report
Ascending Aortic False Aneurysm Formation Associated with Rupture of Acute Type A Aortic Dissection Yoshitaka Yamane, MD, Shogo Mukai, MD, Hironobu Morimoto, MD, and Shuhei Okubo, MD
A 63-year-old man with ruptured acute type A aortic dissection was referred to our hospital. Computed tomography showed a false aneurysm arising from the false lumen located beside the ascending aorta. His hemodynamic status was stable inspite of the ruptured acute aortic dissection. We consider that the containment of the false aneurysm by thin mediastinal structures prevented worsening of his hemodynamic status, and this is extremely rare.
Keywords: aneurysm, aortic dissection, aortic operation
Introduction False aneurysm of the ascending aorta unrelated to trauma, or previous aortic or cardiac surgery is extremely rare. The false aneurysm is surrounded and controlled by closely-related thin mediastinal structures. When the pressure in the false aneurysm exceeds the maximally tolerated tension of the surrounding tissue, fatal rupture occurs.1) In particular, a false aneurysm that forms rapidly has a thin and fragile wall, and emergent surgery is needed. We report a rare case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection.
Case Report A 63-year-old man with a history of hypertension was admitted to another hospital because he had sudden syncope. Computed tomography (CT) revealed acute type A aortic dissection, and he was referred to our hospital for Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama, Hiroshima, Japan Received: October 19, 2014; Accepted: December 18, 2014 Corresponding author: Yoshitaka Yamane, MD. Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, 2-39 Midorimachi, Fukuyama, Hiroshima 720-0804, Japan Tel: +81-84-931-1111, Fax: +81-84-925-9650 E-mail: [email protected]
Annals of Vascular Diseases Vol. 8, No. 1 (2015)
05_10_cr_00122_Yamane.indd 49
surgery. When he arrived at our hospital, his hemodynamic status was stable, his blood pressure was 110/78 mmHg and his heart rate was 78 beats/min (regular). CT films from the referring hospital showed pericardial effusion and a ruptured type A aortic dissection with a primary entry tear in the distal aortic arch (Fig. 1A). In addition, there was a false aneurysm arising from the false lumen that was enhanced in the early phase (Fig. 1B). The false aneurysm was located beside the ascending aorta and expanding into the transverse sinus (Fig. 1C, D). We performed an emergency operation. After median sternotomy, the pericardial cavity was found to be filled with old blood, and there was no pericardial adhesion. Total cardiopulmonary bypass was initiated with retrograde perfusion through the femoral artery and bicaval venous drainage with left ventricular venting. After antegrade cold blood cardioplegia was selectively administered, cardiac arrest was obtained. However we could not find the tear of adventitia which had caused the false aneurysm, we could identify the false aneurysm surrounded by connective tissue and hematoma. We thought that the tear of adventitia was located in the ascending aorta because adventitia of the aortic root was not ruptured. The transected proximal stump of the ascending aorta was reconstructed with both inner and outer Teflon felt. He was cooled to 28°C, the ascending aorta was opened and selective antegrade cerebral perfusion was established. We performed total arch replacement using Dacron graft. Thoracic endovascular aortic repair was performed to close the primary entry 12 days after the surgery. The false aneurysm was not seen on the postoperative CT (Fig. 2), and his postoperative course was satisfactory.
Discussion False aneurysm is a rare and life threatening complication that occurs in 0.5% of all cardiac surgical cases.2) False aneurysm of the thoracic aorta results from transmural disruption of the aortic wall and is contained by the surrounding mediastinal structures. When the pressure in the 49
2015/03/12 11:48
Yamane Y, et al.
(A)
(B) FL TL FA
FL TL
(C)
PA
(D) FL PA TL FA FL TL
FA
Fig. 1 Preoperative computed tomography (CT). Preoperative CT showed type A aortic dissection with a primary entry tear in the distal aortic arch (A). A false aneurysm, which was enhanced in early phase, was located beside the ascending aorta arising from the false lumen (B: white arrow) and expanding into the transverse sinus (C, D). FA: false aneurysm; TL: true lumen; FL: false lumen; PA: pulmonary artery.
Fig. 2 Postoperative computed tomography angiography. The false aneurysm was not seen.
false aneurysm exceeds the maximally tolerated wall tension of the surrounding tissue, fatal rupture occurs and emergent treatment is needed. Various mechanisms for the formation of false aneurysm have been reported, including infection, poor anastomotic technique during surgery and intrinsic aortic wall disease.1–2) However, 50
05_10_cr_00122_Yamane.indd 50
there are few reports of false aneurysm formation associated with acute aortic dissection. In our case, the patient’s hemodynamic status was stable when he arrived at our hospital, in spite of the ruptured acute aortic dissection. Although the false lumen of the dissected ascending aorta penetrated into the pericardial cavity, it was contained by thin mediastinal structures within the transverse sinus, and this resulted in the formation of a false aneurysm and prevention of further bleeding. This is the reason for the patient’s stable hemodynamics status. Pretre, et al. reviewed a series of case with blunt injury of the ascending aorta. They reported that 14 of 21 patients who could be treated surgically presented mainly with false aneurysm of the ascending aorta and appeared in stable condition.3) When the adventitia of the dissected aorta developed a small tear, the blood pressure fell suddenly, resulting in the formation of a false aneurysm contained by thin connective tissue surrounding the ascending aorta. In our case, we believe that the false aneurysm was formed by the same mechanism as when the patient experienced syncope. In addition, we believe there is another reason a false aneurysm was formed. The ascending aorta had retrograde dissection, and the blood pressure at the rupture Annals of Vascular Diseases Vol. 8, No. 1 (2015)
2015/03/12 11:48
Ascending Aortic False Anuerysm
site from the false lumen was lower than the actual aortic blood pressure. In our case, the patient might have had favorable conditions for the formation of a false aneurysm. We sometimes experience false aneurysm of the arch or descending aorta. However, false aneurysm formation associated with a ruptured ascending aorta and a stable hemodynamic condition is extremely rare. We believe that the patient’s hemodynamic stability was due not only to hemostasis, but also involved the process of re-rupture of the dissected aorta.
Conclusion Formation of a false aneurysm may prevent further bleeding, allowing the patient to maintain a stable hemodynamic status and undergo surgery. However, the false aneurysm may rupture again, since it forms rapidly, and has a thin
Annals of Vascular Diseases Vol. 8, No. 1 (2015)
05_10_cr_00122_Yamane.indd 51
and fragile wall. Therefore, surgery should be performed as swiftly as possible.
Disclosure Statement The authors have no conflicts of interest to declare.
References 1) Malvindi PG, van Putte BP, Heijmen RH, et al. Reoperations for aortic false aneurysms after cardiac surgery. Ann Thorac Surg 2010; 90: 1437-43. 2) Atik FA, Navia JL, Svensson LG, et al. Surgical treatment of pseudoaneurysm of the thoracic aorta. J Thorac Cardiovasc Surg 2006; 132: 379-85. 3) Prêtre R, LaHarpe R, Cheretakis A, et al. Blunt injury to the ascending aorta: three patterns of presentation. Surgery 1996; 119: 603-10.
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