Case Study
Surgery for false aneurysm developing after type A acute aortic dissection
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1090–1092 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314534248 aan.sagepub.com
Kazım Ergu¨ne¸s, Levent Yilik, Ismail Yurekli, Ersin Celik and Ali Gurbuz
Abstract Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.
Keywords Aneurysm, false, aortic aneurysm, aortic diseases, blood vessel prosthesis implantation, postoperative complications
Introduction False aneurysm of ascending aorta developing after aortic surgery is uncommon and has high morbidity and mortality rates.1 False aneurysms progressively expand, compress, and erode the surrounding structures, or are a source of persistent infection and systemic embolism. Resternotomy is hazardous and may result in massive and uncontrollable hemorrhage if the false aneurysm is entered. We describe a case of false aneurysm developing due to loosening of the proximal anastomotic sutures 2 years after acute type A aortic dissection repair.
Case report A 49-year-old man was admitted to the emergency department with chest pain and a left parasternal pulsatile mass. His systolic blood pressure was 110 mm Hg in the right arm and 50 mm Hg in the left arm. Right and left femoral arterial pulses were palpable. He had peripheral vascular disease. The left popliteal artery pulse was palpable, and the right popliteal artery, right and left distal pulses were detectable with handheld Doppler. Color Doppler ultrasonography showed severe stenosis of the right deep and superficial femoral artery. Neurological examination was normal. A computed tomography scan showed a false aneurysm thoroughly filling the space between the prosthetic graft and
the sternum. The false aneurysm had eroded the left parasternum and was about to burst out of the skin (Figure 1). Two years earlier, he had undergone aortic valve replacement with a 23-mm St. Jude Medical prosthesis (St. Jude Medical, Inc., MN, USA) and insertion of 24-mm woven Dacron tube graft between the sinotubular junction of the proximal ascending and proximal descending aorta. Another 20-mm woven Dacron tube graft had been anastomosed in an end-to-end fashion to the common flap of the left common carotid and innominate arteries, and this tube graft was inserted into the tube graft between the ascending and proximal descending aorta in an end-to-side fashion. In the first operation, the left subclavian artery had been ligated because of the intensely fragile structure and dissection of this artery. On reoperation, the patient was anticoagulated with heparin, and cannulated before sternotomy under general anesthesia. A long 32 F venous cannula was advanced until the tip was positioned in the right atrium. A 22 F arterial cannula was advanced
Department of Cardiovascular Surgery, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey Corresponding author: Kazım Ergu¨ne¸s, 2040-2 Sokak, Selc¸uk-3, No. 2 Daire-56, Mavi¸sehir 35540, Kar¸sıyaka-Izmir, Turkey. Email: [email protected]
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Figure 1. Computed tomography showing a false aneurysm eroding the left parasternum and about to burst out of the skin.
to the left femoral artery. Cardiopulmonary bypass was established with a flow rate of 2.2 Lmin1m2. Systolic blood pressure was pharmacologically adjusted to less than 80 mm Hg. The rectal temperature was lowered to 18 C. When internal jugular venous oxygen saturation was >95%, circulatory arrest was established. The sternal reentry opened the false aneurysm, causing profuse hemorrhage. Cardiotomy suction was continued as the sternal edges were separated carefully. This allowed the borders of the false aneurysm to be dissected from the posterior sternal table, and the native aorta to be identified distally. The roof of the aneurysm cavity was removed, and the cavity was thoroughly debrided. Gross observation revealed a major leakage from the sinotubular junction anastomosis region of the ascending aorta tube graft. There were no signs of infection around the prosthetic graft. An arterial perfusion cannula was placed into the proximal end of the tube graft anastomosed to the common flap of the left common carotid and innominate arteries, and selective antegrade cerebral perfusion was achieved with this perfusion cannula. The cause of the major leakage from the proximal end of the graft anastomosed between the sinotubular junction of the ascending and descending thoracic aorta was slack sutures (Figure 2). The leakage stopped almost completely after the sutures were tightened, indicating that suture loosening was the cause of the false aneurysm. The suture line was also buttressed with interrupted monofilament sutures of 3/0 polypropylene. The cardiopulmonary bypass and circulatory arrest times were 160 and 16 min, respectively. Three units of erythrocyte suspension and 4 units of fresh frozen plasma were transfused postoperatively. The patient was given antibiotic treatment in the postoperative period. The intensive care unit and hospital stay were 2 and
Figure 2. The cause of the major leakage from the proximal end of the graft anastomosed between sinotubular junction of ascending aorta and descending thoracic aorta appeared to be slack sutures.
11 days, respectively. The patient was given warfarin 5 mg daily preoperatively, and discharged on warfarin 5 mg per day (international normalized ratio 2.5) and aspirin 100 mg per day. He was hospitalized after developing a hemorrhagic stroke due to warfarin overdose (international normalized ratio 10), and died in the 3rd postoperative month.
Discussion The incidence of late reoperation after repair of acute type A aortic dissection ranges between 10% and 24%.2,3 False aneurysm developing after thoracic aortic dissection surgery is an important complication and life-threatening. Surgical treatment in patients with mediastinal false aneurysm is mandatory because of the risk of rupture, cardiac tamponade due to the mass effect of the false aneurysm, and cerebral embolism from a thrombus in the false aneurysm.4 The predominant predisposing factors for false aneurysm are aortic graft infection, dissection of the native aorta, slack anastomotic sutures, increased tissue fragility in the anastomotic suture line, and degenerative aortic disease.5–7 Our patient had no graft infection. The cause of suture loosening 2 years after the first operation may be due to elongation of the polypropylene suture, becoming thinner gradually over the years of Teflon felt swelling and gradual thinning of the edematous and swollen aortic wall following aortic surgery in the acute phase of aortic dissection. Hence we recommend adding several simple sutures to buttress the anastomosis. The degree of anticoagulation is an important factor affecting complications and mortality during follow-up. With low-dose aspirin in combination with oral anticoagulation, the frequency of major hemorrhage is between 1.1% and 2.7% in patients undergoing prosthetic heart valve
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replacement.8 In our patient, a fatal hemorrhagic stroke developed due to warfarin overdose because of improper use of warfarin during follow-up. Cardiopulmonary bypass and deep hypothermia before sternal reentry are important to allow time to expose and dissect the adhesions with circulatory arrest or a low-flow state if a false aneurysm is opened. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Mohammadi S, Bonnet N, Leprince P, et al. Reoperation for false aneurysm of the ascending aorta after its prosthetic replacement. surgical strategy Ann Thorac Surg 2005; 79: 147–152. 2. Kobuch R, Hilker M, Rupprecht L, et al. Late reoperations after repaired acute type A aortic dissection. J Thorac Cardiovasc Surg 2012; 144: 300–307.
3. Tan ME, Morshuis WJ, Dossche KM, et al. Long-term results after 27 years of surgical treatment of acute type A aortic dissection. Ann Thorac Surg 2005; 80: 523–529. 4. Coselli JS, Bavaria JE, Fehrenbacher J, et al. Prospective randomized study of a protein-based adjunct in cardiac and vascular anastomotic repair procedures. J Am Coll Surg 2003; 197: 243–252. 5. Kazui T, Washiyama N, Bashar AH, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001; 72: 509–514. 6. Kirsch M, Soustelle C, Houel R, Hillion ML and Loisance D. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002; 123: 318–325. 7. Villavicencio MA, Orszulak TA, Sundt TM 3rd, et al. Thoracic aorta false aneurysm: what surgical strategy should be recommended? Ann Thorac Surg 2006; 82: 81–89. 8. Levin M, Raskob G, Landefeld S and Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest 1998; 114(Suppl): 511S–523S. (Available at: http:// journal.publications.chestnet.org/data/Journals/CHEST/ 21888/511S.pdf?resultClick¼1. Accessed April 10, 2014.
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Surgery for false aneurysm developing after type A acute aortic dissection
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1090–1092 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314534248 aan.sagepub.com
Kazım Ergu¨ne¸s, Levent Yilik, Ismail Yurekli, Ersin Celik and Ali Gurbuz
Abstract Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.
Keywords Aneurysm, false, aortic aneurysm, aortic diseases, blood vessel prosthesis implantation, postoperative complications
Introduction False aneurysm of ascending aorta developing after aortic surgery is uncommon and has high morbidity and mortality rates.1 False aneurysms progressively expand, compress, and erode the surrounding structures, or are a source of persistent infection and systemic embolism. Resternotomy is hazardous and may result in massive and uncontrollable hemorrhage if the false aneurysm is entered. We describe a case of false aneurysm developing due to loosening of the proximal anastomotic sutures 2 years after acute type A aortic dissection repair.
Case report A 49-year-old man was admitted to the emergency department with chest pain and a left parasternal pulsatile mass. His systolic blood pressure was 110 mm Hg in the right arm and 50 mm Hg in the left arm. Right and left femoral arterial pulses were palpable. He had peripheral vascular disease. The left popliteal artery pulse was palpable, and the right popliteal artery, right and left distal pulses were detectable with handheld Doppler. Color Doppler ultrasonography showed severe stenosis of the right deep and superficial femoral artery. Neurological examination was normal. A computed tomography scan showed a false aneurysm thoroughly filling the space between the prosthetic graft and
the sternum. The false aneurysm had eroded the left parasternum and was about to burst out of the skin (Figure 1). Two years earlier, he had undergone aortic valve replacement with a 23-mm St. Jude Medical prosthesis (St. Jude Medical, Inc., MN, USA) and insertion of 24-mm woven Dacron tube graft between the sinotubular junction of the proximal ascending and proximal descending aorta. Another 20-mm woven Dacron tube graft had been anastomosed in an end-to-end fashion to the common flap of the left common carotid and innominate arteries, and this tube graft was inserted into the tube graft between the ascending and proximal descending aorta in an end-to-side fashion. In the first operation, the left subclavian artery had been ligated because of the intensely fragile structure and dissection of this artery. On reoperation, the patient was anticoagulated with heparin, and cannulated before sternotomy under general anesthesia. A long 32 F venous cannula was advanced until the tip was positioned in the right atrium. A 22 F arterial cannula was advanced
Department of Cardiovascular Surgery, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey Corresponding author: Kazım Ergu¨ne¸s, 2040-2 Sokak, Selc¸uk-3, No. 2 Daire-56, Mavi¸sehir 35540, Kar¸sıyaka-Izmir, Turkey. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 18, 2015
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Figure 1. Computed tomography showing a false aneurysm eroding the left parasternum and about to burst out of the skin.
to the left femoral artery. Cardiopulmonary bypass was established with a flow rate of 2.2 Lmin1m2. Systolic blood pressure was pharmacologically adjusted to less than 80 mm Hg. The rectal temperature was lowered to 18 C. When internal jugular venous oxygen saturation was >95%, circulatory arrest was established. The sternal reentry opened the false aneurysm, causing profuse hemorrhage. Cardiotomy suction was continued as the sternal edges were separated carefully. This allowed the borders of the false aneurysm to be dissected from the posterior sternal table, and the native aorta to be identified distally. The roof of the aneurysm cavity was removed, and the cavity was thoroughly debrided. Gross observation revealed a major leakage from the sinotubular junction anastomosis region of the ascending aorta tube graft. There were no signs of infection around the prosthetic graft. An arterial perfusion cannula was placed into the proximal end of the tube graft anastomosed to the common flap of the left common carotid and innominate arteries, and selective antegrade cerebral perfusion was achieved with this perfusion cannula. The cause of the major leakage from the proximal end of the graft anastomosed between the sinotubular junction of the ascending and descending thoracic aorta was slack sutures (Figure 2). The leakage stopped almost completely after the sutures were tightened, indicating that suture loosening was the cause of the false aneurysm. The suture line was also buttressed with interrupted monofilament sutures of 3/0 polypropylene. The cardiopulmonary bypass and circulatory arrest times were 160 and 16 min, respectively. Three units of erythrocyte suspension and 4 units of fresh frozen plasma were transfused postoperatively. The patient was given antibiotic treatment in the postoperative period. The intensive care unit and hospital stay were 2 and
Figure 2. The cause of the major leakage from the proximal end of the graft anastomosed between sinotubular junction of ascending aorta and descending thoracic aorta appeared to be slack sutures.
11 days, respectively. The patient was given warfarin 5 mg daily preoperatively, and discharged on warfarin 5 mg per day (international normalized ratio 2.5) and aspirin 100 mg per day. He was hospitalized after developing a hemorrhagic stroke due to warfarin overdose (international normalized ratio 10), and died in the 3rd postoperative month.
Discussion The incidence of late reoperation after repair of acute type A aortic dissection ranges between 10% and 24%.2,3 False aneurysm developing after thoracic aortic dissection surgery is an important complication and life-threatening. Surgical treatment in patients with mediastinal false aneurysm is mandatory because of the risk of rupture, cardiac tamponade due to the mass effect of the false aneurysm, and cerebral embolism from a thrombus in the false aneurysm.4 The predominant predisposing factors for false aneurysm are aortic graft infection, dissection of the native aorta, slack anastomotic sutures, increased tissue fragility in the anastomotic suture line, and degenerative aortic disease.5–7 Our patient had no graft infection. The cause of suture loosening 2 years after the first operation may be due to elongation of the polypropylene suture, becoming thinner gradually over the years of Teflon felt swelling and gradual thinning of the edematous and swollen aortic wall following aortic surgery in the acute phase of aortic dissection. Hence we recommend adding several simple sutures to buttress the anastomosis. The degree of anticoagulation is an important factor affecting complications and mortality during follow-up. With low-dose aspirin in combination with oral anticoagulation, the frequency of major hemorrhage is between 1.1% and 2.7% in patients undergoing prosthetic heart valve
Downloaded from aan.sagepub.com by guest on November 18, 2015
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replacement.8 In our patient, a fatal hemorrhagic stroke developed due to warfarin overdose because of improper use of warfarin during follow-up. Cardiopulmonary bypass and deep hypothermia before sternal reentry are important to allow time to expose and dissect the adhesions with circulatory arrest or a low-flow state if a false aneurysm is opened. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Mohammadi S, Bonnet N, Leprince P, et al. Reoperation for false aneurysm of the ascending aorta after its prosthetic replacement. surgical strategy Ann Thorac Surg 2005; 79: 147–152. 2. Kobuch R, Hilker M, Rupprecht L, et al. Late reoperations after repaired acute type A aortic dissection. J Thorac Cardiovasc Surg 2012; 144: 300–307.
3. Tan ME, Morshuis WJ, Dossche KM, et al. Long-term results after 27 years of surgical treatment of acute type A aortic dissection. Ann Thorac Surg 2005; 80: 523–529. 4. Coselli JS, Bavaria JE, Fehrenbacher J, et al. Prospective randomized study of a protein-based adjunct in cardiac and vascular anastomotic repair procedures. J Am Coll Surg 2003; 197: 243–252. 5. Kazui T, Washiyama N, Bashar AH, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001; 72: 509–514. 6. Kirsch M, Soustelle C, Houel R, Hillion ML and Loisance D. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002; 123: 318–325. 7. Villavicencio MA, Orszulak TA, Sundt TM 3rd, et al. Thoracic aorta false aneurysm: what surgical strategy should be recommended? Ann Thorac Surg 2006; 82: 81–89. 8. Levin M, Raskob G, Landefeld S and Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest 1998; 114(Suppl): 511S–523S. (Available at: http:// journal.publications.chestnet.org/data/Journals/CHEST/ 21888/511S.pdf?resultClick¼1. Accessed April 10, 2014.
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