Ann Thorac Surg 1999;67:1798-1800
© 1999 The Society of Thoracic Surgeons
Case Reports
Repair of an ascending aorta pseudoaneurysm by way of superior ministernotomy
Mario Gaudino, MDa,
Francesco Alessandrini, MDa,
Carlo Canosa, MDa,
Gianfederico Possati, MDa
a Department of Cardiac Surgery, Catholic University, Rome, Italy
Accepted for publication November 14, 1998.
Address reprint requests to Dr Gaudino, Divisione di Cardiochirurgia, Policlinico Universitario A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy
e-mail: mgaudino{at}pelagus.it
 |
Abstract
|
|---|
A wide ascending aorta pseudoaneurysm occurring 10 years after uncomplicated aortic valve replacement was successfully repaired using a superior ministernotomy and femoral-femoral cannulation. In this setting, a limited sternal incision minimized the risk of pseudoaneurysm rupture during dissection and allowed safe isolation of the target cardiac structures.
|
Introduction
|
|---|
Ascending aorta pseudoaneurysms (AAPs) are a rare but potentially lethal complication of cardiac operations. Surgical treatment remains a challenging technical procedure. We report the case of a patient in whom a large AAP was successfully treated using a superior ministernotomy, which allowed safe isolation of the target cardiac structures and reduced the risk of intraoperative hemorrhage.
A 63-year-old hypertensive diabetic man had undergone elective replacement of a stenotic aortic valve in 1987. A 25-mm mechanical prosthesis was implanted, and the postoperative course was uneventful. In the following years, the patient remained asymptomatic and in good hemodynamic compensation; serial transthoracic echocardiographic controls documented normal function of the mechanical valve and of the left ventricle. In December 1997, a control transesophageal echocardiogram demonstrated a large mass arising from the ascending aorta with intraluminal evidence of low flow. A subsequent magnetic resonance angiogram of the thorax documented a huge aortic pseudoaneurysm (maximum diameter, 7.7 cm) arising from the right side of the ascending aorta 2 cm above the aortic valve. The neck of the pseudoaneurysm was short (15 mm in length), and there was intraluminal evidence of low flow and no thrombus formation. The pseudoaneurysm lay just below the inferior third of the sternum and was in apposition to the posterior sternal plate (Fig 1). Urgent repair of the pseudoaneurysm was scheduled.
View larger version (91K):
[in this window]
[in a new window]
|
Fig 1. (A) Preoperative magnetic resonance angiogram of the thorax (sagittal view) demonstrates the huge ascending aorta pseudoaneurysm. (B) Higher magnification shows that the pseudoaneurysm lies just below the inferior third of the sternum.
|
|
At operation, the right common femoral artery and vein were cannulated before the chest was reopened. A superior ministernotomy (a longitudinal incision from the top of the bone to the fourth intercostal space and a transverse T incision at that level) was performed according to the description of Gundry [1], and the distal ascending aorta and the main pulmonary artery were freed of adhesions to clamp the aorta and vent the left heart. No dissection was performed at the level of the proximal ascending aorta and the right atrium, where the pseudoaneurysm was located. Normothermic cardiopulmonary bypass was established, the aortic clamp was placed, the ascending aorta was opened 1.5 cm above the previous aortotomy, and antegrade normothermic blood cardioplegia was delivered directly into the coronary ostia.
A large communication between the aortic root and the pseudoaneurysmal cavity was found 1.5 cm above the noncoronary sinus at the level of the previous aortotomy suture (its dehiscence was probably the cause of AAP formation). The pseudoaneurysm was opened, and the communication with the aorta was closed from the outer side using a continuous 4-0 Prolene suture (Ethicon, Sommerville, NJ) reinforced by Teflon pledgets. The mechanical prosthesis appeared to be functioning normally and was left in place. The aortotomy was closed, weaning from cardiopulmonary bypass was uneventful, and the operation was concluded in standard fashion.
The postoperative course was uncomplicated, and the patient was discharged from the hospital on the fifth postoperative day. A control magnetic resonance angiogram of the heart and great vessels demonstrated complete obliteration of the false aneurysm with no residual periaortic leakage (Fig 2). Five months after operation, the patient is symptom free, and control transesophageal echocardiography is unremarkable.
View larger version (116K):
[in this window]
[in a new window]
|
Fig 2. Postoperative magnetic resonance angiogram demonstrates complete obliteration of the pseudoaneurysmal cavity with no residual aortic leakage.
|
|
|
Comment
|
|---|
Postoperative AAP represents a rare (< 1%) complication of cardiac surgical procedures involving cannulation, puncture, or incision of the ascending aorta [2]. The majority of cases occur after aortic valve and coronary artery bypass procedures, usually at the level of the proximal anastomosis (in coronary bypass patients), the aortotomy (in aortic valve patients), or at the cannulation site [3]. Most episodes have an infective etiology, but in a limited percentage of patients, no infection can be demonstrated, and mechanical disruption of the aortic suture seems the most likely causative factor [2]. Although AAPs are usually asymptomatic, compression of vital structures (coronary arteries, saphenous vein grafts, main pulmonary artery) with consequent acute clinical manifestations has sometimes been reported; moreover, the potential risk of pseudoaneurysm rupture (especially in the case of a large AAP) should not be underestimated and mandates early surgical intervention [2, 3].
From a surgical perspective, the treatment of AAP remains challenging. Inadvertent pseudoaneurysm rupture during repeat sternotomy or mediastinal dissection (facilitated by the reduction in the periaortic pressure after chest opening and spreading) can lead to catastrophic intraoperative hemorrhage and exsanguination. In fact, Sullivan and co-workers [3] reported a 29% operative mortality rate among 31 patients undergoing AAP repair, and more recently, Razzouk and colleagues [4] noted six perioperative deaths in a series of 13 patients having repair of postoperative AAP. In both studies, a notable proportion of intraoperative deaths were due to AAP rupture with consequent fatal hemorrhage.
In our patient, the use of a superior ministernotomy (Gundry’s incision) obviated the highly dangerous reopening of the inferior part of the sternum (which was in direct contact with the pseudoaneurysm as shown in Figure 1) and allowed safe isolation of the target cardiac structures with no need to dissect in the area of the pseudoaneurysm. Only after aortic clamping and establishment of full cardiopulmonary bypass was the AAP isolated and incised. Moreover, the avoidance of deep hypothermia and circulatory arrest led to obvious advantages in terms of postoperative bleeding and neurologic outcome.
In conclusion, a superior ministernotomy is particularly indicated when operating on an AAP arising from the lower portion of the ascending aorta and lying just below the inferior part of the sternum. In such a complex setting, the use of this or other ministernotomy incisions [5], besides providing obvious advantages in terms of patient comfort and cosmetic results, allows safe isolation of the target cardiac structures and minimizes the risk of fatal intraoperative hemorrhage.
|
References
|
|---|
-
Gundry S.R. Aortic valve replacement by mini-sternotomy. Operative Techniques Cardiac Thorac Surg 1998;1:47-53.
-
Sabri M.N., Henry D., Wechsler A.S., Di Sciascio G., Vetrovec G.W. Late complications involving the ascending aorta after cardiac surgery: recognition and management. Am Heart J 1991;121:1779-1783.[Medline]
-
Sullivan K.L., Steiner R.M., Smullens S.N., Griska L., Meister S.G. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138-143.[Abstract/Free Full Text]
-
Razzouk A., Gundry S., Wang N., et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg 1993;59:818-823.[Medline]
-
Svensson L.G. Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
B. Parihar, L. S. D. Choudhary, A. P. Madhu, M. K. Alpha, R. Thankachen, and V. Shukla
Pseudoaneurysm of Ascending Aorta After Aortic Valve Replacement
Ann. Thorac. Surg.,
February 1, 2005;
79(2):
705 - 707.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
