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Ann Thorac Surg 2005;79:152
© 2005 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Baylor College of Medicine, The Methodist DeBakey Heart Center, 6560 Fannin St, Suite 1100, Houston, TX 77030
In their retrospective analysis regarding 28 patients who underwent repair of proximal aortic pseudoaneurysms over a 24-year period, Mohammadi and colleagues have highlighted several key issues [1]. Although the overall operative mortality of 17% compares favorably with other series involving proximal aortic pseudoaneurysms, this article illustrates the substantial mortality and morbidity associated with these complex procedures. This emphasizes the importance of preventing pseudoaneurysms during the initial repair and follow-up period. For example, since their introduction in the 1980's, the Kouchoukos open button and Cabrol techniques of coronary artery reattachment have decreased the incidence of coronary pseudoaneurysm after composite valve graft insertion. In this article, of the 14 patients who had undergone aortic root replacement as the initial procedure, only 2 had classic Bentall procedures, and only 1 had a coronary pseudoaneurysm develop. Other surgical techniques developed specifically to optimize anastomotic integrity, which are beyond the scope of this discussion, have been described in detail elsewhere [2–7]. It is notable that 71% of the pseudoaneurysms in this series occurred after repairs performed for acute dissection, and that the false aneurysms developed despite the use of surgical glue. Whereas many surgeons routinely use adhesives to enhance hemostasis during aortic operations, others have raised concerns regarding secondary tissue necrosis, re-dissection, and pseudoaneurysm formation; as such, the role of adhesives in preventing false aneurysms remains unclear. Postoperative threats to anastomotic integrity include graft infection, which can cause pseudoaneurysms long after the initial operation. This justifies an aggressive approach to antibiotic prophylaxis whenever patients with thoracic aortic grafts undergo invasive procedures that produce bacteremia, regardless of the interval since the graft repair. Continued tobacco abuse and poorly controlled hypertension may also contribute to pseudoaneurysm formation by exacerbating progressive aortic degeneration.
Secondly, based on the high incidence of emergency presentation (18%) and its attendant mortality (60%), the authors have emphasized the importance of close follow-up after thoracic aortic repairs. The substantial variability in the interval between the initial aortic repair and the reoperation justifies lifelong surveillance, including the careful evaluation of "even minor symptoms." Close follow-up with annual computed tomographic scans, as suggested by the authors, should increase the chances of early detection, complete repair in an elective setting, and improved outcomes.
Finally, the authors have presented a rational strategy for cannulation based on risk factors for rupture during sternal reentry. Supported by the absence of fatal exsanguination in the series, their novel approach of bilateral carotid artery cannulation for the high-risk subset certainly warrants consideration when planning these repairs.
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