HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Gosta Pettersson Marcos Nores Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pettersson, G. Articles by Gillinov, A. M. Search for Related Content PubMed PubMed Citation Articles by Pettersson, G. Articles by Gillinov, A. M. Related Collections Great vessels

Ann Thorac Surg 2004;77:311-312
© 2004 The Society of Thoracic Surgeons

---

Case report

Transfemoral control of ruptured aortic pseudoaneurysm at aortic root reoperation

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication April 14, 2003.

^* Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, F24, 9500 Euclid Ave, Cleveland, OH 44195, USA
e-mail: gillinom{at}ccf.org

	Abstract

Top Abstract Introduction Comment References

 
Median sternotomy in the setting of aortic pseudoaneurysm and/or rupture is hazardous, requiring technical modifications to prevent exsanguination. Free aortic disruption, particularly when accompanied by aortic regurgitation, presents a particularly challenging situation. The critical issue is to protect the brain and heart while obtaining control of the aorta. We report management of such a case using transfemoral balloon aortic occlusion.

	Introduction

Top Abstract Introduction Comment References

 
Median sternotomy in the setting of aortic pseudoaneurysm and/or rupture is hazardous, requiring technical modifications to prevent exsanguination. In such cases, it may be necessary to establish cardiopulmonary bypass and even circulatory arrest before sternotomy. Port access techniques, including endoluminal balloon occlusion of the aorta, offer particular advantages in the setting of aortic disruption or pseudoaneurysm. We report management of such a case using transfemoral balloon occlusion.

A 43-year-old man with aortic stenosis had aortic valve replacement with a 25 mm St. Jude prosthesis. Seven months later, he presented with prosthetic valve endocarditis and aortic root abscess caused by Enterobacter aerogenes. Antibiotics were started, and he underwent aortic root replacement with an allograft. Two weeks later, he developed mediastinitis. This was treated by mediastinal debidement and mobilization of omental and pectoralis flaps to cover the allograft and close the incision. The patient had recurrent fever and malaise. An echocardiogram demonstrated endocarditis involving the allograft, and the patient was transferred to The Cleveland Clinic Foundation.

Upon arrival, the patient was lethargic but neurologically intact. Echocardiogram revealed a large aortic root abscess cavity and pseudoaneurysm with disruption of the proximal allograft suture line and severe periprosthetic aortic regurgitation. There was major disruption of the distal aortic suture line with a large jet of blood exiting the aorta and entering the same large pseudoaneurysm that occupied most of the pericardial space. The right ventricle was compressed by this blood, and right ventricular function was mildly depressed. The left ventricle was displaced laterally, but left ventricular function was normal.

We proceeded with an urgent operation. The left femoral artery and vein were exposed and cannulated with Heartport cannulas (21F arterial, 25F venous, Heartport, Redwood, CA). Under transesophageal echo guidance, a retrograde cardioplegia catheter was placed via the right internal jugular vein. Cardiopulmonary bypass was instituted and systemic cooling commenced. A balloon occlusion catheter was introduced via the femoral artery cannula and positioned at the level of the disrupted allograft-aortic anastomosis. When the heart fibrillated at a systemic temperature of 28⁰C, the intra-aortic balloon was inflated directly over the distal aortic perforation in an attempt to seal the rupture (Fig 1). With some manipulation, we were able to achieve aortic occlusion, as assessed by reduced pressure at the balloon tip.

View larger version (56K): [in this window] [in a new window]   Fig 1. The balloon-tipped catheter is placed through the femoral artery. Under echocardiographic guidance, the balloon is inflated at the level of the disrupted distal aortic suture line, preventing exsanguination at median sternotomy. The femoral venous cannula is not shown. (Dashed lines = descending aorta.)

The patient was neurologically intact and extubated the day after surgery. He received a permanent pacemaker, recovered rapidly, and was discharged on postoperative day 15. Blood cultures and intraoperative cultures were negative. Pathology revealed suppurative acute inflammation of the allograft and surrounding soft tissue with transmural necrosis. The patient was discharged to home with a 6-week course of intravenous antibiotics and continues to do well 18 months after surgery.

	Comment

Top Abstract Introduction Comment References

 
The combination of ascending aortic disruption, large mediastinal pseudoaneurysm, and aortic regurgitation presented a formidable technical challenge. The critical factor that facilitated successful management of this patient was the use of an intra-aortic balloon catheter to seal the distal allograft anastomotic leak. Ascending aortic control by balloon occlusion is safe and effective [1]. Balloon occlusion at the level of the disrupted suture line between the allograft and native aorta enabled us to complete most of the difficult dissection on cardiopulmonary bypass, minimizing the period of circulatory arrest. Although we still encountered some bleeding from the aorta, this was manageable, and we required only a brief period of circulatory arrest to gain control of the aorta. In addition, balloon occlusion of the ascending aorta coupled with transjugular placement of a retrograde cardioplegia catheter facilitated myocardial protection. D'Attellis et al. reported similar use of Port-Access technology to overcome surgical concerns to manage a pseudoaneurysm of the ascending aorta [2].

An alternate strategy would have been to institute femoral bypass, cool and place a left ventricular vent via a small left thoracotomy to prevent ventricular distension. Using this strategy, once the patient is cooled sufficiently, the pump is shut off and the entire dissection completed under circulatory arrest. Because of dense adhesions, omental and pectoralis flaps, and severe inflammation, this would have necessitated a 30- to 40-minute period of hypothermic circulatory arrest in this case. In addition, it is likely that severe aortic regurgitation would have caused ventricular distension, even with a left ventricular vent in place.

Balloon occlusion was used to control an aortic disruption and facilitate myocardial protection in a complex and threatening reoperative setting. In this case, a reoperation with dense adhesions, balloon inflation did not cause further aortic damage; in other instances, particularly in a primary operation or aortic dissection, it is possible that the balloon might cause more aortic damage. Nevertheless, the strategy of balloon occlusion of aortic disruption is potentially lifesaving and should be considered in the management of difficult patients, particularly those with the combination of mediasinal pseudoaneurysm and aortic regurgitation [3].

	References

Top Abstract Introduction Comment References

 

1. Galloway A.C., Shemin R.J., Glower D.D., et al. First report of the port access international registry. Ann Thorac Surg 1999;67:51-58.[Abstract/Free Full Text]
2. D'Attellis N., Diemont F.F., Julia P.L., et al. Management of pseudoaneurysm of the ascending aorta performed under circulatory arrest by port-access. Ann Thorac Surg 2001;71:1010-1011.[Abstract/Free Full Text]
3. Byrne J.G., Aklog L., Adams D.H., Cohn L.H., Aranki S.F. Reoperative CABG using left thoracotomy: a tailored strategy. Ann Thorac Surg 2001;71:196-200.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. G. Reyes, G. B. Pettersson, T. Mihaljevic, and E. E. Roselli A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system Interactive CardioVascular and Thoracic Surgery, November 1, 2009; 9(5): 893 - 895. [Abstract] [Full Text] [PDF]

				J. Bachet, M. Pirotte, F. Laborde, and D. Guilmet Reoperation for Giant False Aneurysm of the Thoracic Aorta: How to Reenter the Chest? Ann. Thorac. Surg., May 1, 2007; 83(5): 1610 - 1614. [Abstract] [Full Text] [PDF]

				F. A. Atik, J. L. Navia, L. G. Svensson, P. R. Vega, J. Feng, M. E. Brizzio, A. M. Gillinov, B. G. Pettersson, E. H. Blackstone, and B. W. Lytle Surgical treatment of pseudoaneurysm of the thoracic aorta. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 379 - 385. [Abstract] [Full Text] [PDF]

				D. Maselli, G. Santise, A. Montalto, and F. Musumeci Endovascular Aortic Clamping for Pseudoaneurysms of the Aortic Root With Aortic Regurgitation Ann. Thorac. Surg., October 1, 2005; 80(4): 1303 - 1308. [Abstract] [Full Text] [PDF]

				D. Maselli and F. Musumeci Transaxillary Aortic Endoclamping for Ascending Aortic Pseudoaneurysm and Dissected Descending Aorta Ann. Thorac. Surg., June 1, 2005; 79(6): e36 - e38. [Abstract] [Full Text] [PDF]

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): Gosta Pettersson Marcos Nores Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pettersson, G. Articles by Gillinov, A. M. Search for Related Content PubMed PubMed Citation Articles by Pettersson, G. Articles by Gillinov, A. M. Related Collections Great vessels