Ann Thorac Surg 2002;74:268-270
© 2002 The Society of Thoracic Surgeons
How to do it
A simple trick for repairing coronary pseudoaneurysm complicating a Bentall operation
Joseph D. Schmoker, MD*a,
D. Craig Miller, MDb
a Division of Cardiothoracic Surgery, Fletcher Allen Health Care and the University of Vermont, Burlington, Vermont, USA
b Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
Accepted for publication February 18, 2002.
* Address reprint requests to Dr Schmoker, Center for Thoracic Aortic Disease, Fletcher 454, 111 Colchester Ave, Burlington, VT 05401 USA
e-mail: joseph.schmoker{at}vtmednet.org
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Abstract
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Coronary pseudoaneurysms are a known complication of the Bentall wrap-inclusion method of composite valve grafting. We describe two cases to illustrate a straightforward technique for repair and prevention of coronary pseudoaneurysm formation.
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Introduction
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The wrap-inclusion method of composite valve grafting (CVG) introduced by Bentall and De Bono in 1968 [1] for repair of aortic root aneurysms has generally been abandoned around the world in favor of end-to-side, full-thickness Carrel button coronary ostial reimplantation. One reason is that the Bentall procedure has been associated with development of pseudoaneurysms at the coronary ostial suture line [2–4]. Various techniques have been used at reoperation to address this complication, ranging from simple suture repair to complete replacement of the CVG [3, 4]. Two examples are presented to illustrate a simple and straightforward technique for revision of the coronary ostial reimplantation site, which will prevent recurrent pseudoaneurysm formation and coronary ostial dehiscence.
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Patients and technique
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Patient 1
A 49-year-old female with an uncharacterized type of connective tissue disorder was Air-Evac’ed to Stanford University Medical Center from a hospital in Canada 8 days after repair of an acute type A aortic dissection with the Bentall technique using a St. Jude CVG (St. Jude Medical, St. Paul, MN). Notably, gelatin-recorcin-formal (GFR) glue had been used to strengthen the aortic tissues. Complications included major bleeding, inability to wean from mechanical ventilation, and a left hemispheric cerebral embolic stroke. Transesophageal echocardiography revealed right coronary artery ostial dehiscence, normal left ventricular systolic function, and organized pericardial effusion. A computed tomographic angiogram confirmed a large right coronary ostial pseudoaneurysm, big pericardial effusion, and persistent downstream dissection to the level of the iliac arteries. She recovered rapidly from her stroke and was extubated. Reoperation was carried out 10 days after admission. The wrapped aortic sac contained extensive amounts of old and new thrombus; dehiscence of the right coronary ostial reimplantation site was encountered. The aortic tissue around the coronary ostia and distal aortic anastomosis was black in color and appeared to be necrotic, but no organisms were cultured. The distal ascending aorta and proximal transverse arch were replaced under hypothermic circulatory arrest. The right coronary ostial suture line was taken down such that the right coronary artery could be mobilized as a button, which was tedious due to extensive and very dense scarring and inflammatory changes around the ostium. The hole in the CVG was approximately 1.5 cm in diameter, far too large to accommodate the coronary button. Therefore, a separate piece of woven double velour Hemashield graft fabric (MediTech Division, Boston Scientific, Natick, MA) was sharply made into a circular patch that corresponded to the size of the hole and was sewn in place with a running 4-0 polypropylene suture. Then a handheld ophthamological cautery was used to make a small hole that corresponded to the size of the native right coronary ostium within the new circular patch, to which the coronary button was directly sewn using a running 5-0 polypropylene suture. Care was taken to place the sutures near the ostium to obliterate the aortic wall remnant (Fig 1).
Pathologic examination of the aorta from the distal anastomosis and pericoronary reimplantation sites confirmed cystic medial degeneration, partial thickness necrosis, and severe inflammation. The patient recovered uneventfully, and is doing well 4 years later. A helical computed tomographic scan at 2 years revealed no evidence of recurrence.
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Fig 1. Operative technique showing patch closure of the composite valve graft coronary ostial hole with attachment of the mobilized coronary button. (LCA = left coronary artery; RCA = right coronary artery.)
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Patient 2
Twelve years before this admission, a 38-year-old male with Marfan syndrome underwent aortic root replacement at the Medical Center Hospital of Vermont for aneurysm and aortic valve regurgitation with a St. Jude CVG using the Bentall wrap-inclusion technique. On late follow-up he was found to have a 6-cm pseudoaneurysm diagnosed by computed tomographic scan and echocardiogram. Angiography revealed that the origin of the pseudoaneurysm was at the right coronary ostial suture line (Fig 2A).
At reoperation, the wrap was found to contain both organized and fresh thrombus. The right coronary ostial suture line was dehisced over one quarter of its circumference. This suture line was taken down, and the right coronary artery was easily mobilized as a full-thickness button. The hole in the CVG was too large to fit the size of the smaller coronary artery button; therefore, a circular patch of woven double velour Hemashield fabric was used to close the large defect in the original graft. Although the left coronary ostial suture line appeared intact when visualized through the hole in the CVG, temporary pressurization of the graft with blood (after patching the right coronary hole) revealed additional bleeding from the region of the left coronary ostial suture line. Therefore, the distal anastomosis between the aorta and the CVG was taken down, and partial dehiscence of the left coronary suture line was found. The left coronary artery was then mobilized as a full-thickness Carrel button. The equally large hole in the CVG (where the left main coronary ostium had been reattached) was closed with another circular woven double velour Hemashield patch. Appropriately-sized holes were created in both patches with the ophthamological cautery, and the coronary buttons were then sewn directly to the patches with running 5-0 polypropylene sutures, again taking care to place the sutures near the ostia (Fig 1). This patient had an uneventful recovery and is doing well at 1 year follow-up. An echocardiogram at 6 months revealed a normal functioning prosthesis without pseudoaneurysm.
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Fig 2. Preoperative angiograms from patient 2. (A) Right coronary artery injection in right anterior oblique projection shows filling of the pseudoaneurysm (large arrowhead). Small arrowhead points to the silhouette of the composite valve graft. (B) Composite valve graft injection in left anterior oblique projection shows nonexcluded ectatic aorta surrounding the coronary ostia (arrowheads).
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Comment
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Although the true incidence of coronary ostial pseudoaneurysm formation unrelated to infection in patients after aortic root replacement using the Bentall technique is unknown, such has occurred over variable lengths of time in at least 8% to 10% of patients [2, 3]. This problem is more commonly seen in patients with intrinsic weakness of the aortic wall, such as in those with Marfan syndrome or acute aortic dissection. The development of coronary ostial pseudoaneurysm has also been attributed to tension developing on the suture line caused by blood under pressure accumulating within the aortic wrap. Excessive amounts of tension on the side-to-side coronary ostial anastomosis in large aneurysms, even without bleeding, can also predispose to pseudoaneurysm formation. Furthermore, holes made in the CVG to reattach the coronary ostia using this technique are often made quite large to facilitate construction of the suture line. This leaves a substantial amount of abnormal aortic tissue, which may weaken over time, predisposing to both pseudoaneurysm and true coronary ostial aneurysms [5] (Fig 2B). Preventing these complications requires using a hole in the graft only as large as the internal diameter of the main coronary ostium. At Stanford, a complete wrap-inclusion Bentall CVG procedure has never been performed, relying instead on the end-to-side, tension-free anastomoses to full-thickness Carrel coronary buttons, which have been widely mobilized [6, 7]. Finally, the use of GRF glue in the first case may have been responsible in part for the early postoperative anastomotic dehiscence, as recently reported by Kazui and coworkers’ [8] group.
There is relatively little written material concerning techniques to repair these pseudoaneurysms. Several studies have mentioned revision by simple suture repair, conversion to a Cabrol-II "moustache" modification for coronary revascularization [3], or complete replacement of the CVG with direct implantation of coronary buttons [4]. Simple suture repair may leave weakened tissue behind which may predispose to recurrent pseudoaneurysm formation or the genesis of true ostial aneurysms. The Cabrol-II modification can be associated with kinking of the smaller caliber coronary graft, and the proper geometry can be tricky to achieve in a redo setting when peri-aortic fibrosis and scarring is commonly quite prominent. Replacement of the entire CVG seems unnecessary, unless an annular pseudoaneurysm is present.
We describe a relatively simple technique that allows for conversion of the Bentall repair into a tension-free coronary button repair. In the two patients we described, the holes previously made in the CVG using the Bentall technique were far too large; therefore, they were simply closed with circular patches, and the coronary buttons were then sewn into the smaller holes within the patches.
Some difficulty in mobilization of the coronary button was encountered in the subacute case described, perhaps caused by the prior use of GFR glue. In other redo circumstances, however, this step after a previous CVG operation or aortic repair for aortic dissection using Teflon felt (Impra Inc, Tempe, AZ) can be exceptionally hazardous. One author (JDS) recently performed this technique on a patient with a failed Bentall who had undergone two prior sternotomies with liberal placement of Teflon felt. Both coronary buttons were successfully mobilized and reimplanted, although in a somewhat tedious fashion. In cases where it is simply too dangerous to mobilize the arteries, we believe that the Cabrol-II coronary moustache graft is a good option for coronary revascularization.
The second case illustrates another important point; even though there was no indication of leakage from the left coronary ostial suture line, pressurizing the CVG after taking down the wrap revealed a major dehiscence. All anastomoses, therefore, should be aggressively evaluated at reoperation regardless of the findings from the preoperative diagnostic studies.
In summary, coronary ostial pseudoaneurysms can occur after a Bentall repair, as emphasized by Kouchoukos and colleagues [2]. These patients should be followed regularly forever using serial imaging studies. If a pseudoaneurysm is detected, conversion to a coronary button repair can be performed safely and without the need for complete replacement of the CVG. Even in patients with normal appearing ostial suture lines who are undergoing repeat operation, time should be taken to assess these other suture lines for defects. If such defects are found, or if there is an ectatic coronary button caused by excessive aortic tissue initially being used, consideration should be given to the simple button repair described here.
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References
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- Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Kouchoukos N.T., Wareing T.H., Murphy S.F., Perillo J.B. Sixteen-year experience with aortic root replacement. Ann Surg 1991;214:308-320.[Medline]
- Aoyagi S., Kosuga K., Akashi H., Oryoji A., Oishi K. Aortic root replacement with a composite graft: results of 69 operations in 66 patients. Ann Thorac Surg 1994;58:1469-1475.[Abstract]
- Hahn C., Tam S.K.C., Vlahakes G.J., Hilgenberg A.D., Akins C.W., Buckley M.J. Repeat aortic root replacement. Ann Thorac Surg 1998;66:88-91.[Abstract/Free Full Text]
- Taniguchi K., Nakano S., Matsuda H., Shirakura R., Sakai K., Okubo N., et al. Long-term survival and complications after composite graft replacement for ascending aortic aneurysm associated with aortic regurgitation. Circulation 1991;84(Suppl III):III31-III9.
- Yun K.L., Miller D.C., Fann J.I., et al. Composite valve graft versus separate aortic valve and ascending aortic replacement. Is there still a role for the separate procedure?. Circulation 1997;96(Suppl II):II368-II75.[Medline]
- Miller D.C., Mitchell R.S. Composite aortic valve replacement and graft replacement of the ascending aorta plus coronary ostial reimplantation: how I do it. Sem Thorac Cardiovasc Surg 1993;5:74-83.[Medline]
- Kazui T., Washiyama N., Bashar A.H.M., et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001;72:509-514.[Abstract/Free Full Text]
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Abstract
Introduction
