Ann Thorac Surg 2000;70:1714-1716
© 2000 The Society of Thoracic Surgeons
Case report
Graft replacement for huge aneurysm of the main pulmonary artery
Kenji Kuwaki, MDa,
Kiyofumi Morishita, MDa,
Kanshi Komatsu, MD, PhDa,
Tomio Abe, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
Address reprint requests to Dr Kuwaki, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-0061, Japan
e-mail: kuwaki{at}d8.dion.ne.jp
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Abstract
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We present 2 cases of huge aneurysm of the main pulmonary artery without significant pulmonary artery hypertension or intracardiac shunt. Both patients underwent surgery where resection of the aneurysm and graft replacement, using Hemashield prosthesis (Meadox Medicals, Oakland, NJ), was performed. They are now leading normal lives without any symptoms.
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Introduction
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Aneurysm of the main pulmonary artery is very rare. The natural history of pulmonary artery aneurysm is not well understood and clear guidelines for the treatment of this disease do not exist. We describe 2 cases of huge main pulmonary artery aneurysm which were treated surgically.
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Case reports
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Patient 1
A 63-year-old woman was admitted to our hospital because of increased fatigability, shortness of breath, and chest pain. She had undergone right ventricular outflow tract reconstruction using Rygg’s pericardial patch (Polystan, Vaerlose, Denmark) for pulmonary valve stenosis and aneurysmorrhaphy for main pulmonary artery aneurysm at the age of 54 years. Histologic examination of the resected pulmonary arterial specimen showed mucoid degeneration of media and fragmentation of elastic fiber. Thereafter, she had been in good general condition until the age of 62 years.
Computed tomography showed a markedly dilated main pulmonary artery that measured 12 x 6.3 cm in diameter (Fig 1A). Cardiac catheterization revealed a systolic pressure gradient of 10 mm Hg across the pulmonary valve with systolic pulmonary artery pressure of 35 mm Hg. Main pulmonary artery angiogram identified a severe pulmonary valve regurgitation.
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Fig 1. (A) Computed tomographic scan shows a huge dilatation of the main pulmonary artery in case 1. (B) Digital subtraction angiogram demonstrates severe enlargement of main pulmonary artery in case 2.
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At operation, the main pulmonary arterial trunk, proximal portion of bilateral main pulmonary arteries, and moderately shrunken pulmonary valve were excised. The main pulmonary artery and pulmonary valve were reconstructed with composite graft which was made of 30-mm Hemashield graft (Meadox Medicals, Oakland, NJ) and 23-mm Carpentier-Edwards porcine bioprosthesis (Baxter Edwards, Horw, Switzerland). The proximal right and left pulmonary arteries were replaced with 26-mm Hemashield graft. Then, the distal end of the composite graft was anastomosed to the side of the Hemashield graft previously implanted between the right and left pulmonary artery (Fig 2A). She is now doing well at 3 years and 4 months follow-up.
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Fig 2. (A) T-shaped graft replacement with 30-mm and 26-mm Hemashield woven Dacron prostheses for main pulmonary artery aneurysm including pulmonary valve replacement using porcine bioprosthesis. (B) Graft replacement using 24-mm and 22-mm Hemashield prostheses in case 2.
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Patient 2
A 66-year-old man was referred to our hospital with a diagnosis of aneurysm of the main pulmonary artery, pulmonary valve stenosis, and DeBakey type IIIb aortic dissection. He had symptoms of chest pain. The onset of aortic dissection was 2 months before admission.
Cardiac catheterization revealed that the pressure gradient over the pulmonary valve was 25 mm Hg with a pulmonary artery systolic pressure of 34 mm Hg. Digital subtraction angiography revealed a huge aneurysm of the main pulmonary artery (Fig 1B). There was no surgical indication for DeBakey type IIIb aortic dissection. At operation, the dilated main pulmonary artery and bifarcation of the pulmonary artery were excised. Commissural fusion between right and anterior pulmonary cusp was identified, and commissurotomy was done with scalpel. Then, the reconstruction of pulmonary trunk was performed using 24-mm and 22-mm Hemashield Dacron (C.R. Bard, Haverhill, PA) grafts as shown in Figure 2B. Histologic examination of the pulmonary arterial wall showed no abnormality. He is leading a normal life at 1 year and 3 months follow-up.
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Comment
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There are controversies regarding the treatment of pulmonary artery aneurysms and it is difficult to make a decision regarding surgical treatment. In some literature, surgical treatment is recommended when the main pulmonary artery aneurysm is discovered, regardless of the etiology [1, 2]. This philosophy is based on the belief, according to the law of Laplace, that the aneurysm will increase and have the potential to rupture. On the other hand, some reports suggest a conservative treatment for main pulmonary artery aneurysm if there is no left-to-right intracardiac shunt or significant pulmonary hypertension [3, 4]. Those articles indicated relatively benign long-term survival with uncomplicated courses for 7 to 10 years in such patients. However, there are case reports in which the main pulmonary artery aneurysm was gradually enlarged, even in the presence of normal pulmonary artery pressure, between 4 to 10 years and treated surgically [5, 6]. Thus, the relationship between the rate of aneurysm enlargement and the level of pulmonary artery pressure is unclear. In our opinion, surgical management should be considered for the patient with huge pulmonary artery aneurysm in spite of the absence of pulmonary hypertension, as in our cases presented herein.
The exact mechanism of the pulmonary artery aneurysm in our patients is unclear, but post-stenotic dilatation of a pulmonary valve stenosis in the structural weakness of the pulmonary arterial wall might be a possible explanation in the development and progress of the pulmonary artery aneurysm. Regarding the operative procedure, we believe that graft replacement is more reliable and durable than aneurysmorrhaphy. There is possibility of recurrent dilatation of the remaining aneurysmal wall after aneurysmorrhaphy, as in our patient 1 described here.
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References
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Tami L.F., McElderry M.W. Pulmonary artery aneurysm due to severe congenital pulmonic stenosis. Case report and literature review. Angiology 1994;45:383-390.
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Accepted for publication January 20, 2000.
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Abstract
Introduction
