Ann Thorac Surg 1996;62:1834-1835
© 1996 The Society of Thoracic Surgeons
Case Report
Dissection of the Ascending Aorta: A Late Complication of Coronary Artery Bypass Grafting
Hitoshi Yaku, MD, PhD,
Gary G. Fermanis, FRACS,
R. John Macauley, FRACP,
David A. Horton, FRACS
Department of Cardiothoracic Surgery, The St. George Hospital, Sydney, Australia
Accepted for publication June 19, 1996.
 |
Abstract
|
|---|
Acute dissection of the ascending aorta as a late complication of coronary artery bypass grafting has been rarely reported. We report a case of a 61 year-old man in whom acute dissection of the ascending aorta developed 2 years after coronary artery bypass grafting. The ascending aorta was replaced with a Dacron graft, and an island of the aortic wall, on which previous proximal anastomoses had been placed, was implanted into the Dacron graft successfully.
|
Introduction
|
|---|
Dissection of the ascending aorta at the time of coronary artery bypass grafting is an uncommon but well-documented complication [1–3]. However, dissection of the ascending aorta occurring late after coronary artery bypass grafting is rare [3, 4]. We report a case of acute dissection of the ascending aorta occurring 2 years after coronary artery bypass grafting and successful repair.
A 61-year-old man had sudden onset of severe back pain radiating through to the buttock while teeing off at a golf course. He was transferred to The St. George Hospital. The patient had undergone coronary artery bypass grafting using three separate saphenous vein grafts 1 year 10 months before this episode. On admission, blood pressure was 130/70 mm Hg. Chest roentgenography showed enlargement of the mediastinal shadow. Chest and abdominal computed tomography showed dissection of the thoracic aorta arising in the ascending aorta and extending as far as the bifurcation of the common iliac arteries. A transesophageal echocardiogram showed an intimal flap arising just above the aortic valve. Neither aortic regurgitation nor pericardial effusion was detected. While the patient was under observation, ischemia of both legs developed, and urgent operation for the aortic dissection was undertaken (36 hours after the admission).
Under general anesthesia, redo median sternotomy was performed. The ascending aorta was dilated (about 6 cm in diameter). Cardiopulmonary bypass was established between the right femoral artery and the right atrium. The patient was cooled down to 19°C, and the circulation was arrested. When the aorta was transected, it became clear that the dissection had arisen from an area of the aorta between the proximal anastomoses of the previous saphenous vein grafts. The intimal flap was thin and friable, implying that the dissection had occurred recently. The native coronary orifices were not involved in the dissection. An island of the ascending aortic wall, on which the proximal anastomoses of the saphenous vein grafts had been placed, was excised and the intimal flap was attached to the outer layer with gelatin-resorcin-formol (GRF) glue [5]. A cross-clamp was then applied to the distal ascending aorta and the circulation was recommenced. Gelatin-resorcin-formol glue was injected in the dissected layer of the proximal aortic stump. After about 5 minutes, a 30-mm Dacron prosthesis (Gelseal, Vascutek, Scotland) was sewn into the proximal ascending aorta using 4-0 Prolene (Ethicon, Somerville, NJ) continuous sutures. The circulation was again arrested and the cross-clamp was removed. The distal aortic flap was repaired using GRF glue in the same fashion as the proximal aorta. The distal end of the graft was sewn to the ascending aorta using 4-0 Prolene continuous sutures. A portion of the Dacron graft was removed and the island of ascending aortic wall with the proximal anastomoses was anastomosed into the Dacron graft using 4-0 Prolene continuous sutures (Fig 1
). The circulation was then recommenced, and the patient was rewarmed. Weaning from the cardiopulmonary bypass was uneventful using a low-dose adrenaline infusion. Transitory renal impairment developed, and the patient needed ventilatory support for 5 days postoperatively. However, recovery from those complications was satisfactory and the patient was discharged on the 12th postoperative day. The patient remains well 1 year 6 months after the operation.
View larger version (28K):
[in this window]
[in a new window]
|
Fig 1. . Repair of the ascending aorta. The previous coronary grafts were implanted to the Dacron graft as an island.
|
|
|
Comment
|
|---|
In coronary artery bypass grafting, the ascending aorta is subjected to manipulations such as cannulation, cross-clamping, partial clamping, and proximal anastomoses of grafts. Each manipulation could cause disruption of the intima of the ascending aorta, resulting in pseudoaneurysm [2, 6] or acute dissection of the ascending aorta [1–3]. Acute dissection of the ascending aorta at the same time as coronary operation or immediately after operation and its management have been reported [1–3]. However, acute aortic dissection occurring late after the initial coronary operation is rarely reported [3, 4]. Nicholson [3] reported acute dissection of the ascending aorta occurring 8 months after coronary bypass grafting. However, it was assumed that dissection occurred at the time of operation, and details of the attempted surgical repair were not reported. Bopp and associates [4] reported ascending aortic dissection occurring 4 months after coronary bypass grafting, and this was treated conservatively. In our patient, acute dissection of the ascending aorta occurred 2 years after the initial coronary operation. We think that it is reasonable to assume that the dissection of the ascending aorta occurred in a weakened part of the intima of the aortic wall, associated with the proximal anastomoses. It has been reported that uncontrolled hypertension is a major risk factor in the causation of aortic dissection after open heart operations [2, 3]. This patient had a long history of hypertension and was receiving oral atenolol. Although his blood pressure on admission was in a normal range, he may well have been hypertensive beforehand and his blood pressure might have dropped into the normal range with the onset of the dissection.
To repair the dissection of the ascending aorta, we adopted femoral arterial and right atrial cannulations and circulatory arrest in the same way as in an ordinary case with acute dissection of the ascending aorta. We routinely use GRF glue to reconstruct the layers of the proximal and distal ends of the aorta. We find that graft anastomosis is easier and more secure using GRF glue than using Teflon felt strips. For management of the previous coronary grafts, the island of the ascending aortic wall including all proximal anastomoses was excised and repaired with GRF glue [5]. This island was implanted into the Dacron graft that had been used to replaced the ascending aorta. This proved to be a simple and secure technique in dealing with the intimal tear and previous coronary grafts, and there have been no untoward effects during follow-up.
|
Footnotes
|
|---|
Address reprint requests to Dr Fermanis, Department of Cardiothoracic Surgery, The St. George Hospital, Kogarah, NSW 2217, Australia.
|
References
|
|---|
- Litchford B, Okies E, Sugimura S, Starr A. Acute aortic dissection from cross-clamp injury. J Thorac Cardiovasc Surg 1976;72:709–13.[Abstract]
- Boruchow IB, Iyengar R, Jude JR. Injury to ascending aorta by partial-occlusion clamp during aorta-coronary bypass. J Thorac Cardiovasc Surg 1977;73:303–5.[Abstract]
- Nicholson WJ. Aortic root dissection complicating coronary bypass surgery. Am J Cardiol 1978;41:103–7.[Medline]
- Bopp P, Perrenoud JJ, Periat M. Dissection of ascending aorta. Rare complication of aortocoronary venous bypass surgery. Br Heart J 1981;46:571–3.[Abstract/Free Full Text]
- Guilmet D, Bachet J, Goudot B, et al. Use of biological glue in acute aortic dissection. Preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 1979;77:516–21.[Abstract]
- Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138–43.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
D. Jain, H. B. Gehl, H. A. Katus, and G. Richardt
Penetrating Atherosclerotic Ulcer of the Ascending Aorta: A Delayed Complication of Coronary Artery Bypass Surgery: A Case Report
Angiology,
March 1, 2003;
54(2):
251 - 255.
[Abstract]
[PDF]
|
|
|
|
|
|
|
O. Chavanon, M. Carrier, R. Cartier, Y. Hebert, M. Pellerin, P. Page, and L. P. Perrault
Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery?
Ann. Thorac. Surg.,
January 1, 2001;
71(1):
117 - 121.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
