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Ann Thorac Surg 1999;68:1406-1407
© 1999 The Society of Thoracic Surgeons

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Case Reports

Unusual origin and fistulization of an aortic pseudoaneurysm: "off-pump" surgical repair

^a Department of Cardiac Surgery, Tor Vergata University, Rome, Italy

Address reprint requests to Dr Chiariello, Department of Cardiac Surgery, Tor Vergata University of Rome, European Hospital, Via Portuense 700, 00149 Rome, Italy

	Abstract

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Aortic pseudoaneurysm is an unusual complication of cardiac operations. The origin depends on the site of arterial wall disruption. Rupture into the right side of the bronchial tree is an exceedingly rare evolution. Repair is commonly performed using cardiopulmonary bypass. In our report a male patient underwent two procedures for aortic dissection, and 6 months after the second operation massive hemoptysis appeared abruptly. A false aneurysm rose from a graft-to-graft anastomotic site and ruptured into a segmental bronchus of the right upper lobe. Repair was performed without cardiopulmonary bypass.

	Introduction

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Pseudoaneurysm of the ascending aorta is an unusual complication after cardiovascular operations. Rupture into the right side of the bronchial tree is an exceptional cause of hemoptysis because of the distance from the ascending aorta. Blood flooding into the airways is a potentially fatal evolution and requires prompt surgical treatment. Cardiopulmonary bypass is commonly used to excise the aneurysm and repair the bronchial tear.

In our report the mass rose from a graft-to-graft anastomotic site as the patient underwent two procedures for aortic dissection 4 years and 6 months previously. Massive hemoptysis was caused by rupture into a segmental bronchus of the right upper lobe. Successful surgical treatment was performed without cardiopulmonary bypass.

A 58-year-old man was first admitted to our hospital in July 1993, because of type I aortic dissection. Operation involved replacement of the ascending aorta and the inner curvature of the aortic arch with a 30-mm Dacron–Hemashield prosthesis (Meadox Medicals, Oakland, NJ), using profound hypothermia and circulatory arrest. He remained asymptomatic for 3 years.

In December 1996 he underwent a Bentall procedure because of dissection of the residual proximal aortic root with aortic valve incompetence. A 26-mm Dacron–Hemashield composite tubular graft containing a size 23 St. Jude Medical valve (St. Jude Medical, St. Paul, MN) was inserted. The graft-to-graft anastomosis was performed using a running 4-0 Prolene suture (Ethicon, Somerville, NJ). He was discharged on the ninth postoperative day.

The patient was readmitted after 6 months because of a sudden onset of massive hemoptysis. Chest roentgenogram showed a widened mediastinum and abnormal radiopacities on the right side. Transesophageal echocardiography revealed a compressive mass along the entire aortic graft. On computed tomographic scan, the mass was recognized as an anterior mediastinal hematoma compressing the proximal aortic arch and the superior vena cava; hemorrhage within the right lung was evident (Fig 1). The patient was taken to the operating theater for the third time, in a desperate condition. The right femoral artery was prepared for cardiopulmonary bypass before the sternum was opened. After median sternotomy was performed, a wide false aneurysm of 10 by 10 cm in diameter appeared lying between the right lung and the prosthetic aorta, compressing the superior vena cava. The fibrous sac was opened, fresh clots removed, and a 3-mm disrupted site of anastomosis between the two prosthetic aortic grafts was found to be the cause of bleeding. This site was then closed with 4-0 Prolene suture. An inspection of the aneurysmal cavity revealed a fistulization into a segmental bronchus of the right upper lobe, which was closed with a continuous 5-0 Prolene suture. The mass was excised carefully avoiding cardiopulmonary bypass. Culture of the false aneurysm contents proved negative and the patient was discharged on the 18th postoperative day. He is doing well after 1 year.

View larger version (110K): [in this window] [in a new window]   Fig 1. Computed tomogram of the chest showing the pseudoaneurysm compressing both the superior vena cava (thin arrow) and the aortic graft (large arrow). Hemorrhage in the right lung is also visible.

	Comment

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False aneurysms progressively enlarge and may break into the surrounding structures. When they rise from the descending thoracic aorta, rupture into the left lung may be easy because of their close proximity [4]. Conversely, rupture into the right side of the respiratory tract is exceedingly rare because of the distance from the ascending aorta. "True" aneurysms tearing the right lung parenchyma, but sparing the bronchial wall, are also uncommon [5]. Only Favre [4] and Razzouk [6] and their colleagues have described postoperative aortic pseudoaneurysms perforating into the right main stem bronchus. Rupture into lobar or segmental bronchi is even more difficult because of their distal position.

Hemoptysis may appear either intermittently [7], if clots or thrombi block the outlet of blood into the airways for unpredictable periods, or massively [6]. Massive hemoptysis is the hallmark of active arterial bleeding. In such a case urgent operation is indicated. Selective endobronchial intubation is recommended to control possible intraoperative hemorrhaging. Partial or total pneumonectomy is rarely necessary. When the tear in the respiratory tract involves the bronchial wall sparing the lung parenchyma, as in this report, direct 5-0 Prolene suture is sufficient for repair. In previous reports pseudoaneurysms of the ascending aorta have always been repaired using cardiopulmonary bypass [3–7], in association with profound hypothermia and circulatory arrest in selected patients [8]. However, even if avoidance of cardiopulmonary bypass is possible, as in our patient, the common femoral artery should always be prepared before opening the sternum, as the false aneurysm may rupture causing fatal hemorrhage during sternotomy. In some extreme cases cardiopulmonary bypass and cardiac arrest should be started even before opening the sternum.

The reported time between the initial operation and the onset of hemoptysis may range from 1 to 17 years (average, 8 years) [4]; nevertheless, in our patient hemoptysis set in after a 6-month interval. We believe that in each patient who has previously undergone cardiac operation, a false aneurysm communicating with the respiratory tract should be suspected at the first onset of hemoptysis.

	References

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1. Keon W.J., Bédard P., Akyurekli Y., Brais M. Causes of death in aortocoronary bypass surgery. Ann Thorac Surg 1977;23:357-360.[Abstract]
2. Kouchoukos N.T., Marshall W.G., Jr, Wedige-Stecher T.A. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
3. 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]
4. Favre J.P., Gournier J.P., Adham M., Rosset E., Barral X. Aortobronchial fistula. Surgery 1994;115:264-270.[Medline]
5. Garrett H.E., Ricks R.K., Lewis J.M., Howell J.F., DeBakey M.E. Hemoptysis secondary to aortopulmonary fistula. J Thorac Cardiovasc Surg 1965;49:588-593.
6. 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]
7. Boerema I. Repair of a traumatic false aneurysm of the aorta perforating into the bronchus. J Cardiovasc Surg 1971;12:93-94.[Medline]
8. Williams G.D., Zimmerman G.J., Osam P.N., Scott Daniel M. False aneurysm of aortic cannulation site occurring three years post-operatively. J Cardiovasc Surg 1976;17:266-269.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ruggero De Paulis Luigi Chiariello Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Piciché, M. Articles by Chiariello, L. Search for Related Content PubMed PubMed Citation Articles by Piciché, M. Articles by Chiariello, L.