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Ann Thorac Surg 2004;78:117-120
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Repair of aortic false aneurysm using deep hypothermia and circulatory arrest

^a Department of Surgery, Montreal, Quebec, Canada
² Research Center of the Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada

Accepted for publication January 22, 2004.

^* Address reprint requests to Dr Carrier, Department of Surgery, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec H1T 1C8, Canada
e-mail: michel.carrier{at}icm-mhi.org

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Aortic false aneurysms are a rare complication of surgery of the aorta that can occur several months to years after the initial operation. We reviewed our results with false aneurysm repair using deep hypothermia and circulatory arrest.

METHODS: Eleven patients were reoperated on for false aneurysm of either the ascending or descending thoracic aorta. Femorofemoral cardiopulmonary bypass with full-dose aprotinin and a heparinized system was used in all patients. Hypothermic circulatory arrest at an average of 20°C was instituted in all patients for repair. Six patients had a patch repair with either polyethylene terephthalate fiber (Dacron) or bovine pericardium, 4 had tube replacement of the aorta, and 1 had primary repair of the defect.

RESULTS: Three patients had false aneurysm formation at a site of coarctation repair in the descending aorta, and the 8 others had false aneurysms in the ascending aorta at the site of a previous aortotomy. Six patients had proven infection as the cause; the causative agent was Staphylococcus species in all cases. Mean cardiopulmonary bypass time was 178 ± 51 minutes, and circulatory arrest time averaged 39 ± 18 minutes. Operative mortality was 18% (2 of 11); the cause of death was cardiogenic shock in both patients. The mean time to extubation in survivors was 5 days, and the average time to discharge was 16 days.

CONCLUSIONS: Although mediastinal infection is a common cause, aortic false aneurysms can be safely approached using femorofemoral cardiopulmonary bypass, hypothermic circulatory arrest, and patch repair with acceptable operative mortality and long-term survival.

	Introduction

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Aortic false aneurysms are rare complication of surgical manipulation of the aorta occurring in less than 0.5% of cardiac surgical cases [1]. Numerous etiologic entities have been associated with this complication: namely, patch repair of coarctation of the aorta, graft infection or mediastinitis, poor anastomotic techniques, and poor aortic wall tissue [1–3].

Aortic pseudoaneurysms or false aneurysms are the result of disruption of at least one layer of the wall of the vessel and are contained by the remaining vascular layers and the surrounding structures of the mediastinum. Pseudoaneurysm of the ascending aorta can present as a pulsatile suprasternal mass, evidence of myocardial ischemia as a result of compression of coronary artery bypass grafts, chest pain, dysphagia, and stridor. Patients usually present with general symptoms of fatigue, weight loss, and fever caused by the septic state.

The approach to these patients differs depending on the site and size of the false aneurysm. Numerous reports have been published of the results of aortic false aneurysm repair in the abdominal aorta, but very few series discuss successful repair of the thoracic aorta [4]. We describe our results with surgical repair of false aneurysm of the thoracic aorta using cardiopulmonary bypass (CPB), deep hypothermia, and circulatory arrest.

	Material and methods

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Patient records were retrospectively reviewed for reoperations for false aneurysm of the thoracic aorta. Patient characteristics are described in Table 1. All patients had a preoperative thoracic computed tomographic scan to better localize the site of aneurysm formation and transesophageal echocardiography for detection of aortic valve insufficiency. The cause of false aneurysm formation was previous surgery in all cases. No aneurysms had ruptured before operation.

In patients with mediastinal infection, the repair, patch, or tube replacement was covered with pectoralis muscle flaps or epiploplasty.

	Results

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From December 1989 to January 2003, 11 patients were reoperated on for false aneurysm of either the ascending aorta in 8 patients or descending aorta in 3 patients. All were emergency operations. False aneurysms in the ascending aorta arose at the proximal anastomosis of a Bentall repair in 3 patients, the proximal anastomosis of an aortocoronary bypass in 3 patients, and the aortic anastomosis of cardiac transplant in 2 patients. In the descending aorta, false aneurysms arose at the proximal or distal anastomotic sites of repair of aortic coarctation in 3 patients. One patient had a recurrent false aneurysm. Six patients had infection as the cause, and in all cases the causative organism was a Staphylococcus species; Staphylococcus aureus in 4 patients, Staphylococcus epidermidis in 1 patient, and methicillin-resistant S aureus in 1 patient.

The aneurysms were repaired using a polyethylene terephthalate fiber (Dacron) tube graft in 3 patients, patch repair with bovine pericardium in 4 patients, and Dacron piece in 2 patients, homograft in 1 patient, and primary repair in 1 patient. The average CPB time was 178 ± 51 minutes, and the average time of circulatory arrest was 38 ± 18 minutes. In infected false aneurysms, pectoral muscle flaps or an epiploplasty was used to cover the aneurysm repair. Prolonged systemic intravenous antibiotic treatment was also used.

The hospital mortality was 18% (2 of 11); the 2 patients died of cardiogenic shock in the perioperative period owing to a combination of long operative and CPB times and, probably, inadequate myocardial protection. None of the other patients demonstrated signs of cardiogenic shock and were weaned from bypass with minimal inotropic support. There were 9 operative survivors, and most had an uneventful hospitalization with discharge within 2 weeks. There was 1 patient who had multiple complications including respiratory insufficiency requiring tracheostomy, renal failure, and hemorrhage in the postoperative period. This patient was discharged after 54 days of hospitalization. The mean time to extubation in operative survivors was 5 days, and the average time to discharge was 16 days (Table 1). Follow-up was 80% complete (7 of 9 survivors). Average follow-up was 18 ± 9 months. One patient died at 2 months postoperatively of undiagnosed pericardial tamponade (found at autopsy). The rest of the operative survivors enjoy a good quality of life and have resumed their everyday activities. They have been followed with either yearly echocardiography or magnetic resonance imaging, and none have shown repeated false aneurysm formation.

	Comment

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False aneurysms of the thoracic aorta are a rare complication after surgical manipulation that can appear at sites of anastomosis or cannulation, or at sites of needle puncture for pressure measurements, to purge the aorta of air, or to inject cardioplegic solutions [1–3]. They present a surgical challenge and are usually diagnosed by computed tomographic scans of the thorax or angiography (Figs 1 and 2). Once the diagnosis is made, they are considered surgical emergencies and must be corrected before rupture. Although we understand that false aneurysm of the aorta can result from other causes including tuberculosis, human immunodeficiency virus, and after trauma, the present study focused on those related with surgical manipulation of the aorta [5, 6].

View larger version (52K): [in this window] [in a new window]   Fig 1. Thoracic computed tomographic scans showing a large false aneurysm of the ascending aorta which is adjacent and adherent to the overlying sternum.

View larger version (154K): [in this window] [in a new window]   Fig 2. Angiographic evaluation of the aortic false aneurysm demonstrating a large false lumen and cavity.

Few reports of false aneurysm repair have been published in the literature. Most include case reports [2, 3] of successful repair; the mortality rate associated with these complicated cases is not described, although most would agree that it is easily greater than 20%. We have presented our results with 11 patients with false aneurysm of the thoracic aorta several months to years after the initial intervention. The majority of the patients had false aneurysm of the ascending aorta, and most of these had an infectious etiology. Three had false aneurysms at the site of coarctation repair in the descending aorta.

A recent report from Roth and colleagues [7] in which 10 patients were reoperated on for aneurysm after patch aortoplasty repair of coarctation of the aorta found that there was no mortality and two minor neurologic events using femorofemoral bypass and hypothermic circulatory arrest. Our cohort of 3 patients had uneventful evolution to discharge after repair of the descending thoracic aorta.

Pseudoaneurysms of the ascending aorta carry a much higher morbidity and mortality owing to the risk at sternal reentry and the fact that many of these patients have an infectious etiology and are in a septic state at the time of surgery. We have presented a series of 8 patients with false aneurysm of the ascending aorta. Six of these patients presented with sepsis, all proven with positive hemocultures to a Staphylococcus species. Infection was caused by either direct extension of mediastinitis to the ascending aorta or hematogenous spread. These results are in concordance with the study from Sullivan and colleagues [8], which reviewed outcomes of false aneurysm repair in 31 cases. An infectious organism was implicated in the development of the pseudoaneurysm in 15 patients in their cohort, half of these with a Staphylococcus species as the causative agent. Another study looking at infected abdominal aneurysms [4] identified sepsis as a leading cause of death and was associated with a 40% mortality rate. Two of our patients died of cardiogenic shock within hours of the operative procedure. These results compare favorably to the study by Sullivan and colleagues [8] in which mortality rates during hospitalization were 29%. Operative survivors had uneventful hospitalization to discharge and were alive at follow-up. One patient had a difficult postoperative course with complications of renal failure, pneumonia and respiratory insufficiency requiring tracheostomy, and a long recovery period.

The use of circulatory arrest is essential in all patients as false aneurysm formation of the ascending or descending aorta precluded clamping and infusion of cardioplegia into the coronary ostia. Deep hypothermia was achieved at temperatures of 20°C or lower, temperatures considered safe to undergo circulatory arrest to minimize neurologic injury. Antegrade or retrograde cerebral perfusion was not used in any patients in this cohort. Of the 9 operative survivors, none exhibited neurologic deficits in the postoperative period.

False aneurysm repair was accomplished using one of three techniques; patch repair with Dacron or bovine pericardium, tube replacement with Dacron or homograft, or primary repair. We only had one reoperation for failure of repair in a patient in which primary closure of false aneurysm was the technique of choice. The rest of our cohort enjoyed an uneventful course and were still alive at follow-up. The surgical technique was chosen depending on the size of the false aneurysm lumen and the overall quality of the remaining aorta. If feasible, a patch was used and sutures were anchored in healthy aortic tissue when possible. If the aorta showed uniform fragility and had a tendency for tearing, a Dacron tube graft or homograft replacement was the procedure of choice associated with pectoral muscle flaps or epiploplasty [9].

In conclusion, aortic false aneurysms carry a high mortality and morbidity rate but can be safely approached using femorofemoral CPB, hypothermic circulatory arrest, and patch repair using either Dacron or bovine pericardium with acceptable operative mortality. Infection is a common etiologic factor. Operative survivors show good long-term survival and absence of repeated false aneurysm at follow-up.

	References

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