Ann Thorac Surg 2001;72:1766-1767
© 2001 The Society of Thoracic Surgeons
How to do it
Redo operation for thoracoaortic aneurysm after entire aortic replacement
Akira Ingu, MD*a,
Motomi Ando, MDa,
Yutaka Okita, MDa,
Naoaki Yamada, MDa,
Soichiro Kitamura, MDa
a Department of Cardiovascular Surgery and Radiology, National Cardiovascular Center, Suita, Osaka, Japan
Accepted for publication June 1, 2001.
* Address reprint requests to Dr Ingu, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
e-mail: ingu{at}sapmed.ac.jp
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Abstract
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Resection of a saccular aneurysm that developed in a remnant of aorta in a patient with Marfan’s syndrome, who previously underwent aortic aneurysmectomy, is described. The intercostal arteries were reconstructed end-to-end using small-caliber interposition grafts to the aortic prosthesis. Preoperative magnetic resonance angiography identified the artery of Adamkiewicz and facilitated its preservation.
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Introduction
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The friability of the aortic wall in patients with Marfan’s syndrome makes vascular repairs difficult. In particular, reattaching the intercostal arteries to the aortic prosthesis can be problematic, and some authors have recommended sewing an aortic patch containing the arterial ostia to the prosthesis. This report describes the successful repair of a saccular aneurysm that developed in such an aortic patch. Preoperative magnetic resonance angiography identified the artery of Adamkiewicz and helped preserve it intraoperatively.
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Technique
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A 40-year-old man with Marfan’s syndrome, who had a history of aortic disease, was diagnosed as having a recurrent thoracoaortic aneurysm on chest computed tomography (CT). This patient’s medical history included: a composite graft repair of the aortic root because of acute type A dissection in 1985; descending aortic replacement in June 1991; total arch replacement in November 1991; and thoracoabdominal repair to resect an expanding chronic dissecting aneurysm of the entire aorta in 1995. At that time, the intercostal arteries, including Th8–11, were anastmosed side-to-side to the aortic prosthesis using a patch of native aorta. CT showed aneurysmal change of the aortic patch from which the intercostal arteries originated. The aneurysm was saccular and had enlarged 5 mm over 5 months; its maximum diameter was 53 mm on CT scan (Fig 1). Magnetic resonance angiography (MRA) demonstrated that the artery of Adamkiewicz was supplied from the right Th10 intercostal artery, and rich collateral arteries originated from the right Th6 and left Th9 and Th10 intercostal arteries (Fig 2).
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Fig 1. Computed tomographic scan shows a saccular aortic aneurysm involving the origins of the intercostal arteries. The maximum diameter of the aneurysm was 53 mm.
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Fig 2. Magnetic resonance angiography shows the typical hairpin curve of the artery of Adamkiewicz, supplied by the right Th10 intercostal artery (arrow). The anterior spinal artery is continuous with the artery of Adamkiewicz.
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The surgical approach was through the prior thoracotomy. Exposure of the aortic prosthesis was difficult because adhesions were dense. Because we knew that the aorta was friable from our previous experience, local repair was ruled out and an alternative procedure was decided upon. First, we minimally exposed the aortic prosthesis at the proximal and distal site of the aneurysm carefully so as not to rupture it. Femoro-femoral bypass was established, using a heparin-coated closed circuit, heparin 1 mg/kg was injected systemically, and the previous prosthesis was doubly clamped at the proximal and distal sites of the aneurysm. The prosthesis was incised longitudinally, permitting visualization of the ostia of the Th9 and Th10 intercostal arteries in the aneurysm wall. We created end-to-end anastmoses to the intercostal arteries using 8-mm knitted Dacron vascular grafts (Gelsoft; Vascutek, Renfrewshire, Scotland). Graft replacement was performed with a 24-mm knitted Dacron vascular graft (Gelseal; Vascutek) from the proximal to the distal clamp of the in situ prosthesis. Finally, we created end-to-side anastomoses between each of the 8 mm-grafts and the 24-mm Vascutek graft (Fig 3). The original graft was unclamped, and femoro-femoral bypass was discontinued. Hemostasis was secure, and the chest was closed. The postoperative course was uneventful. The patient did not require transfusion, and he was discharged 3 weeks after the operation.
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Fig 3. Operative procedure. (A) The in situ prosthesis was incised longitudinally, and the ostia of the Th9 and Th10 intercostal arteries were identified, in the wall of the aneurysm. (B) We revascularized the spinal cord by creating end-to-end anastomoses between the new graft, which replaced the aneurysmal segment, and the Th9 and Th10 intercostal arteries supplying the artery of Adamkiewicz, using individual prosthetic grafts.
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The Th9 and Th10 intercostal arteries had good flow on postoperative angiography. Postoperative CT confirmed that the aneurysm wall had been resected, and the intercostal grafts enhanced with contrast medium.
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Comment
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Based on recent success in surgery for thoracoaortic and thoracoabdominal aneurysms, an increasing number of reports of total aortic replacement have been published. In particular, staged replacement of the entire aorta is often required in cases of extended dissecting aneurysm in patients with Marfan’s syndrome because the aortic wall is so friable [1, 2]. By 1999, the authors replaced the entire aorta in 12 patients with Marfan’s syndrome in staged procedures. It has been reported that when a segment of aortic wall is left in situ to facilitate branch reconstruction, it becomes aneurysmal in patients with Marfan’s syndrome [3–5]. For this reason, the authors try to reconstruct branches using graft whenever possible. The present case is unusual because the entire aorta had been replaced piecemeal in four sessions, and the intercostal artery reconstructed en bloc evolved into a saccular aneurysm over 7.5 years. While the patient was asymptomatic, the aneurysm was enlarging rapidly, and surgery could not be avoided. Preoperative MRA assisted us in selecting the site of the reconstruction. Since February 1998, the authors have used MRA preoperatively in collaboration with a radiologist to identify the location of the artery of Adamkiewicz with good results [6]. MRA is noninvasive, simplifies the surgical procedure, and helps prevent inadvertent injury to this vital vessel.
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References
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Crawford E.S., Crawford J.L., Stowe C.L., et al. Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan’s syndrome. Ann Surg 1984;199:358-362.[Medline]
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Finkbohner R., Johnston D., Crawford E.S., et al. Marfan syndrome: long-time survival and complications after aortic aneurysm repair. Circulation 1995;91:728-733.[Abstract/Free Full Text]
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Kouchoukos N.T., Marshall W.G., Wedig-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]
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Ito M., Kazui T., Tamia Y., et al. Coronary ostial aneurysms after composite graft replacement. J Card Surg 1999;14:301-305.[Medline]
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Yamada N., Okita Y., Minatoya K., et al. Preoperative demonstration of Adamkiewicz artery by magnetic resonance angiography in patients with descending or thoracoabdominal aortic aneurysms. Eur J Cardiothorac Surg 2000;18:104-111.[Abstract/Free Full Text]
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Abstract
Introduction
