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Ann Thorac Surg 2005;79:147-152
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Reoperation for False Aneurysm of the Ascending Aorta After Its Prosthetic Replacement: Surgical Strategy

Department of Thoracic and Cardiovascular Surgery, Institute of Cardiology, "La Pitié" Hospital, Paris, France

Accepted for publication June 7, 2004.

^* Address reprint requests to Dr Mohammadi, Department of Thoracic and Cardiovascular Surgery, Institute of Cardiology, "La Pitié" Hospital, 47-83 Bd de L’Hôpital, 75013 Paris, France (E-mail: siamakmohammadi{at}yahoo.com).

	Abstract

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BACKGROUND: This study analyzes surgical approaches of 29 operations carried out for false aneurysms of the ascending aorta after prosthetic replacement (FAA) from January 1979 to April 2003, in 28 patients.

METHODS: Initial operations consisted of a composite valve graft with reimplantation of coronary arteries (n = 14) or a supracoronary tube (n = 14) with 7 aortic valve replacements. Initial pathology included acute aortic dissection (n = 20), aortic annuloectasia (n = 6), and aortic valvulopathies with concomitant aneurysm of the ascending aorta (n = 2). Resternotomy was performed under the following conditions: femoral artery cannulation in 7, femoral artery and vein cannulation in 6, femoral artery, vein, and carotid artery cannulation in 16 patients of whom 6 patients underwent partial circulatory arrest. The FAA ruptured during sternotomy in 9 cases. Operative intervention consisted of direct simple suture repair (n = 7), complete revision (n = 21), and one isolated reimplantation of the coronary artery.

RESULTS: No patients died after FAA rupture during resternotomy. Among the 6 patients who underwent partial circulatory arrest before sternotomy, the FAA ruptured 5 times. Carotid artery cannulation was always justifiable: 2 cases of FAA rupture, 9 cases of aortic arch replacement, and 5 cases with both. The operative mortality was 17.2% (n = 5). Mortality was influenced by the emergent nature of operations (p < 0.05).

CONCLUSIONS: The FAA can be surgically managed with acceptable results through a sternotomy using prior femoro-femoral and carotid cannulation. The latter allows for cerebral perfusion in cases of FAA rupture during resternotomy and is of value for the surgical treatment of these complex lesions.

	Introduction

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False aneurysm occurring after replacement of the ascending aorta by a vascular prosthesis is defined as a total or partial dehiscence of the prosthesis from the aortic wall. It is a rare complication of this type of surgery. As with other aneurysms, it is notable for a marked increase in diameter and the occurrence of life threatening complications such as rupture, fistula formation, compression of adjacent organs, and thrombosis [1].

Despite advances in endovascular techniques, treatment in the majority of cases remains surgical. The procedure is complex, has a high mortality [2, 3], and represents a surgical challenge. The purpose of this study was to analyze the strategy and the results of operations carried out at our institution in a group of 28 patients with 29 operations.

	Material and Methods

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Patients and Initial Disease
From January 1979 to April 2003, 683 and 202 patients survived surgery for ascending aorta aneurysm and aortic dissection operation, respectively, in our institution. During the same time 28 patients underwent a total of 29 reoperations for false aneurysms of the ascending aorta (FAA). Included in this study were all patients with a vascular prosthesis of the ascending aorta in whom a partial or total dehiscence of prosthesis was noted during the operation. The study included 18 men and 10 women with a median age of 54 years (30 to 74 years). The initial disease which resulted in a prosthetic replacement of aorta included: acute dissection of the aorta in 20 cases, aortic annuloectasia in 6 cases, and calcified aortic valve stenosis with aneurysm of the ascending aorta in 2 cases.

Fifteen of the initial operations were performed in our institution and 13 in other centers. The initial operation consisted of replacement of the ascending aorta by a supracoronary vascular tube or a composite valve graft with reimplantation of the coronary vessels. Initial operation and concomitant procedures are depicted in Table 1. Gelatin-resorcin-formol glue, with or without Teflon reinforcement, was used in all patients with acute aortic dissection. The distal and proximal graft anastomoses were performed using monofilament running sutures at the aortic wall juncture and interrupted sutures at the annular level. In 4 patients, two prior cardiac surgery operations were performed before the FAA repair. One patient in this group required a third reoperation, which entailed a revision of the FAA repair. There were no cases of deep mediastinal infection after the initial operation.

Seven fistulas between the aorta and adjacent structures were diagnosed preoperatively: 4 involving the right atrium (not in patients with a Cabrol fistula), one involving the pulmonary artery, one involving the superior vena cava, and one involving the trachea. The anatomic relationship between FAAs and the sternum were evaluated carefully. According to the preoperative investigations the FAA was considered to be anterior in 8 (33.3%) cases and posterior in 16 cases (66.6%).

In the 5 patients in whom the diagnosis of FAA had not been made preoperatively, the indications for reoperation were aortic insufficiency in one case and distal FAA, misinterpreted as true aneurysmal evolution of chronic dissection of the aortic arch, in the other four. All patients underwent operation almost immediately after the diagnosis of FAA was established. Five patients were operated on emergently for cardiogenic shock.

	Surgical Technique

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Extracorporeal Circulation and Cerebral Perfusion
Among these patients, 4 types of cannulation were chosen before sternotomy as precautions for a probable FAA rupture during chest wall reentry:

Level 1: cannulation of the femoral artery;

Level 2: level 1 + cannulation of the femoral vein;

Level 3: level 2 + cannulation of both carotid arteries;

Level 4: level 3 + partial circulatory arrest in hypothermia with antegrade perfusion of carotids.

The distribution of the patients is described in Table 3. The carotid arteries were cannulated through two separate sternocleidomastoid cervical incisions. Two right-angle metal (3.8 or 5.2 mm) cannulas (Terumo Cardiovascular System Corp, Ann Arbor, MI) were inserted into both common carotid arteries through pursestring sutures. Cerebral perfusion was performed through a Y connection off the main arterial line, from a single head on the arterial roller pump that started at the same time as extracorporeal circulation (ECC). Partial circulatory arrest, if needed, was achieved by cooling the patient to 24 to 25°C, occluding the proximal carotid arteries, and reducing bypass flow transiently to 800 to 1,000 mL/min. In this technique, there was no distal perfusion pressure monitoring. In the presence of aortic regurgitation or left to right shunt, hypothermia was established by reducing the perfusate temperature at a slower rate to conserve contractility before complete division of the sternum. The bypass flow was also decreased temporarily. The median duration of aortic cross clamping was 85 minutes (range, 10 to 184 minutes) and that of the ECC was 103 minutes (range, 50 to 230 minutes). Hypothermia with partial circulatory arrest involving the lower part of the body with antegrade perfusion of the carotid arteries was performed a total of 16 times before sternotomy or during operation, with a median duration of 17 minutes (range, 8 to 38 minutes). Antegrade cerebral perfusion was our technique of choice for the aortic arch repair.

SURGICAL REPAIR
The repair (Table 4) was carried out by two principle methods: (1) simple repair by direct suture; (2) extensive repair by refashioning of the anastomosis. There was also one isolated reimplantation of the coronary arteries by Cabrol technique [4]. Concomitant procedures are depicted in Table 5. A diagnosis of prosthetic infection by Staphylococcus epidermidis was confirmed microbiologically in one case. The infected prosthesis was completely replaced with a new graft, and the patient received a 6-week course of intravenous antibiotics without further complication.

	Results

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Mortality and Morbidity
The overall operative mortality was 17.2%. Univariate analysis showed the in-hospital mortality in patients who had emergent operations was significantly higher (60%, n = 3 of 5) than those who had elective operations (8.3%, n = 2 of 24, p < 0.05). No patient died as a consequence of catastrophic hemorrhage during reentry into the chest. Among the 5 patients who died, 4 died on the day of operation either from low cardiac output state (n = 3) or from massive coronary embolism (n = 1). This latter patient had been repaired by simple suture. The fifth patient died on the 8th day after dehiscence of the aortic prosthesis, which had also been repaired by simple suture. Patients with simple suture repair had a higher mortality rate (28.6%, n = 2 of 7) compared with those patients who had undergone complete repair (14.3%, n = 3 of 21). Postoperative complications included low cardiac output state (n = 4), reoperation for bleeding (n = 2), cerebrovascular accidents (n = 1), transient ischemic attacks (n = 1), and septicemia (n = 1).

FAA Rupture; Security Level Risk Analysis
Retrospective analysis of the surgical methods showed that factors leading to levels of precaution 1 or 2 included: unknown preoperative diagnosis of FAA (5 of 5); FAA with posterior extension (8 of 16); operations undertaken during earlier years (mean date = 1986).

Factors leading to levels of precaution 3 or 4 included: FAA with anterior extension (8 of 8); extreme operative urgency (4 of 5); previous replacement of the aortic arch (3 of 3); second and third reoperations (3 of 4); operations undertaken more recently (mean date = 1996).

Of the 16 patients requiring levels 3 or 4 precaution, ten patients fulfilled at least two of these criteria. In the 9 patients where rupture of the FAA occurred during reentry into the chest, 7 patients remained stable. The carotid arteries had already been cannulated in these 7 patients, 5 of whom were already under circulatory arrest. For the 2 other patients where the FAA ruptured during division of the sternum, the FAA was thrombosed in one patient and in the other, the aorta was controlled proximally thus avoiding severe bleeding from the FAA rupture. The FAA was ruptured in 5 of 6 patients who underwent sternotomy while on partial circulatory arrest. Thus, circulatory arrest before the sternotomy was of benefit in 83.3% of cases. Carotid cannulation before reentry into the chest was justified in 100% of cases; 2 cases of FAA rupture, 9 cases of aortic arch replacement, and for both reasons in 5 cases.

	Comment

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Most of the literature contains isolated case reports or small heterogeneous series of the false aneurysm of the thoracic aorta with diverse origins [2, 3, 5–8]. Our series is notable for the number of patients involved, for its homogeneity of false aneurysm origin, and for its therapeutic approach. The FAA is a rare but serious and complex complication of ascending aorta and/or aortic root prosthetic replacement. Its incidence, risk factors, and natural history is unknown. Bachet and colleagues [9] reported 3 false aneurysms in 143 patients operated on initially for acute dissection of the ascending aorta with prosthetic replacement over a 10 year period. Acute aortic dissection was the main initial disease in our series of patients. Out of 15 patients with FAA who had their original operation in our institution, 12 patients (80%) had acute aortic dissection, although it was not the main reason for prosthetic replacement of the ascending aorta in our patients. Despite incomplete long-term follow-up, among 683 patients who survived surgery for ascending aorta aneurysms and 202 patients with aortic dissection, the numbers who developed FAA were 3 and 12, respectively. The incidence of FAA appears to be high in cases of aortic dissection probably due to increased tissue fragility in the suture line of these patients. Other risk factors like mediastinal infection after cardiac surgery [10], Takayatshu’s arteritis [11], and Behcet’s disease [12], which are known to increase the risk of FAA, were not found in our series.

The time interval between the initial procedure and the occurrence of FAA was variable, with a maximum of 17 years. This variability justifies a long-term follow-up of all types of prosthetic replacement of the aortic root and the ascending aorta. The clinical picture is also variable depending on the site of the FAA and involvement of adjacent structures. Thus even minor symptoms in patients with an aortic prosthesis must be taken into account. The diagnosis of FAA is usually made by CT scan or magnetic resonance imaging. These imaging modalities allow one to see the extent of the lesions and progression of initial disease [13, 14]. Analysis of the anatomic relation between the aneurysmal pocket and the sternum directs surgical strategy and ensures that proper degree of precaution is taken before dividing the sternum. We recommend lifelong surveillance with annual CT scans to assess the development of FAA and CT angiography for suspected cases and operative plan (Fig 1).

View larger version (65K): [in this window] [in a new window]   Fig 1. Anterior extension of false aneurysm of the ascending aorta (FAA) after its prosthetic replacement. Computed tomography angiography of the chest in (A) axial view and (B) reconstructed oblique sagittal orientation. Note the FAA containing contrast and surrounding hematoma between the prosthetic ascending aorta (AAo) and the back of the sternum.

Our surgical approach consists of cannulating the femoral vessels and the carotid arteries for cerebral protection or even instituting partial circulatory arrest before reentry into the chest when deemed necessary. This technique allows for mediastinal dissection and control of the distal aorta without compromising cerebral perfusion even in cases of massive hemorrhage. Selective cerebral perfusion through the carotid arteries is the method of choice in our institution and its efficacy for cerebral protection has been demonstrated [15–17]. In our opinion, carotid artery cannulation is appropriate for this type of pathology and has several advantages. In addition to its benefits in cases of FAA rupture and exsanguination, this method allows for good operative exposure by positioning the carotid arteries cannulas outside the operative field. This technique allows for unhurried mediastinal dissection and repair. It can influence the quality of this complex surgical repair. In contrast to deep hypothermia, which requires long perfusion times for cooling and rewarming, the moderate level of hypothermia permits a shorter total bypass time, avoiding the disadvantages of deep hypothermia. In the 7 patients in whom the FAA ruptured upon chest reentry, serious complications were avoided due to this strategy. Carotid perfusion was helpful both before reentry into the chest in cases of FAA rupture and after reentry to allow for replacement of the aortic arch. In view of the potential benefits of these measures, it would seem legitimate to adopt them universally in patients with a high risk of rupture. The retrospective nature of this study does not allow us to identify the morbidities related to this surgical strategy. The results in our series are encouraging for such lethal pathology. Razzouk and colleagues [2] report an operative mortality of 41% in a series of 17 false aneurysms of the ascending aorta occurring after cardiac surgery. The operative mortality for a series of 31 patients without FAA published by Sullivan and colleagues [3], and in 16 cases of false aneurysm in a series of 81 ascending and aortic root reoperations published by Dougenis and colleagues [18], was 29% and 12.5%, respectively. The mortality rate in our series may be attributable to the surgical strategy which limits the risk of fatal bleeding at the beginning of the procedure due to FAA rupture.

The various techniques used in our patients is related to distribution of the patients over a 24 year period and has changed with increasing experience in confronting this type of pathology. Surgical repair was usually complex but in some patients simple sutures in the region of the dehisced prosthesis under ECC were sufficient. Although the latter could be considered as a lifesaving treatment in very high risk patients with limited FAA when feasible, it may not be the best approach in the majority of cases, because of the following reasons: failure to recognize another lesion; suturing in a fragile zone prone to recurrent dehiscence; possible presence of associated endocarditis; and detachment of the neointima of old prosthesis with coronary or systemic emboli. It must be emphasized that the death of patients in the simple repair group was due to complications that may have been avoided by a complete operative revision. Considering the complexity of these cases, severe adhesions between the FAA and adjacent structures, and probable presence of infection, we advise aggressive debridement and complete replacement of the vascular prosthesis using new material sewn at a distance from the old suture lines and the fragile zone. However, homograft aortic root rereplacement for infected composite valve grafts was recommended by several authors [19, 20].

In conclusion, elective cannulation of the carotid arteries allows us an effective and efficient method of cerebral perfusion in cases of FAA rupture during sternotomy. In addition, it is useful for the complete repair of these complex lesions. A well-planned operative strategy guided by preoperative imaging allowing for careful analysis of the lesions, and complete replacement of the previous prosthesis, results in low operative mortality which in turn is related to the preoperative stability of the patients.

	Acknowledgments

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We thank Dr George Berberian and Dr Kenny Wong for their assistance in editing and comments.

	References

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