Ann Thorac Surg 2005;79:2166-2168
© 2005 The Society of Thoracic Surgeons
How to do it
Preoperative Balloon Sealing of a False Ascending Aortic Aneurysm for Safe Redo Sternotomy
Henning Warnecke, MDa,*,
Norbert Franz, MDb,
Stefan Roethemeyer, MDb,
Frank Ritter, MDa,
Alexander T. John, MDa,
Joachim Thale, MDb
a Department of Cardiac Surgery, Schuechtermann-Klinik, Bad Rothenfelde, Germany
b Department of Cardiology, Schuechtermann-Klinik, Bad Rothenfelde, Germany
Accepted for publication January 14, 2004.
* Address reprint requests to Dr Warnecke, Department of Cardiac Surgery, Schuechtermann-Klinik, Ulmenallee 11, 49214 Bad Rothenfelde, Germany (E-mail: hwarnecke{at}schuechtermannklinik.de).
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Abstract
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Sternal contact of aortic aneurysms in redo operations may require specific techniques to safely control bleeding during sternotomy and surgical dissection. This is the first report on the preoperative use of an inflatable balloon to prevent massive hemorrhage by inserting the balloon—a procedure performed in the cardiac catheterization laboratory—before rethoracotomy. A false ascending aortic aneurysm was successfully sealed by transaortic wire-guided balloon placement from the iliac artery. Gentle traction on the inflated balloon catheter, which was placed inside the false aneurysm, effectively sealed the entrance to the aneurysm. A straightforward median redo sternotomy procedure was subsequently performed without blood loss from the unavoidably opened aneurysm. My colleagues and I propose this technique for aneurysms of mycotic or anastomotic origin, which have an anatomically distinct entry channel.
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Introduction
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Aortic aneurysms in direct contact with the sternum remain a technical challenge, especially in redo procedures. In the case of the patient reported here, most surgeons would opt for femorofemoral extracorporeal circulation and a procedure performed with deep hypothermia and circulatory arrest (Fig 1) [1]. However, establishing circulatory arrest without previous venting of the left ventricle, ie, before sternotomy, may be hazardous because of overdistension of the left ventricle. Induction of deep hypothermic arrest is safer if the chest can be opened and the left ventricle drained by a vent catheter to avoid distension of the left ventricle. In our patient, who presented with moderate aortic insufficiency, thoracotomy before the onset of hypothermia-induced ventricular fibrillation was mandatory. A mycotic ascending aortic aneurysm had developed in the patient after 2 previous coronary bypass procedures. The infection probably originated from Teflon (DuPont, Wilmington, DE) pledgets used at the cannulation site during the previous procedure. Definitive repair with xenograft pericardium was performed with deep hypothermic circulatory arrest, and recovery was uneventful [2].
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Fig 1. False aortic aneurysm of mycotic origin after 2 previous transsternal procedures. The aneurysm adheres to the posterior sternal bone (computed tomographic scan courtesy of Dr Bernauer, Guetersloh, Germany).
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Technique
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General anesthesia was induced in the cardiac catheterization laboratory. Vascular access was established by suprainguinal retroperitoneal dissection of the iliac artery, according to the procedure established for stent placement in the descending aorta. Under 2-plane fluoroscopy, a steerable 0.089-cm guidewire (Boston Scientific, Inc, Maple Grove, MN) was advanced into the false ascending aortic aneurysm. An inflatable balloon catheter, designed for use inside aortic stents (Reliant Stent-Graft Balloon Catheter; Medtronic Inc, Minneapolis, MN), was placed in the aneurysm and inflated (Fig 2). The maximum usable balloon diameter is 46 mm, and the usable length is 100 cm. A 12F introducer or direct arteriotomy is required. Simultaneous transesophageal echocardiography revealed complete cessation of blood flow in the entry channel of the aneurysm once gentle traction was applied to the distal end of the balloon catheter (Fig 3). It was subsequently possible to perform redo median sternotomy on femorofemoral extracorporeal circulation. The inflated balloon was exposed immediately during insertion of the sternal spreader, effectively creating a bloodless aneurysm cavity.
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Fig 2. Angiographic demonstration of an inflated balloon inside the false aneurysm (left anterior oblique 70-degree projection). The aneurysm was not injected with contrast medium because of a presumed risk of rupture.
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Fig 3. (A) Transesophageal echocardiography showing blood flow in the entrance to the aneurysm. (B) Gentle traction on the balloon catheter effectively seals the entrance (LA = left atrium; PA = pulmonary artery.)
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Comment
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There is no general consensus on the most appropriate surgical procedure for the patient presented here (Fig 1). Straightforward re-sternotomy with fingertip control of the entry has been advocated, but this may be hazardous if the aortic wall is fragile [3]. The induction of circulatory arrest by using deep hypothermia before thoracotomy requires a competent aortic valve and should be performed under transesophageal echocardiographic control in order not to overlook left ventricular distension after ventricular fibrillation has set in [4]. Once this is observed, expeditious action may be necessary when the desired level of hypothermia has not yet been reached. Bilateral thoracotomy in the bed of the fourth rib without approaching the aneurysm is probably the least hazardous strategy; however, surgical trauma is considerable [1]. The use of an inflatable balloon to control aortic bleeding during thoracotomy has been reported but is, in our view, best reserved for situations of unexpected bleeding [5]. Dislocation of the balloon toward the aortic lumen or toward the aneurysm is not easy to avoid, and balloon expansion may extend tears in a fragile aortic wall. Left ventricular apex venting through a separate small left anterior thoracotomy seems to be helpful in preventing left ventricular distension [6], and the Port-Access technique has likewise been used to achieve protection of the fibrillating heart before thoracotomy [7]. In contrast to the above-mentioned procedures, the technique presented here seems to greatly simplify an otherwise complex procedure. The only prerequisite seems to be that the entrance to the aneurysm should be anatomically distinct and limited in size. The technique should be applicable to both mycotic and anastomotic aneurysms.
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Acknowledgments
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The assistance of M. Puke, B. Ehrhardt, E. Feldkamp, and G. Richardson is gratefully acknowledged.
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References
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- Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissection. New York: Churchill Livingstone; 1996. pp. 306.
- Pasic M, Carrel T, von Segesser L, Turina M. In situ repair of mycotic aneurysm of the ascending aorta Thorac Cardiovasc Surg 1993;105:321-326.
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- Apaydin AZ, Posacioglu H, Islamoglu F, Telli A. A practical tool to control bleeding during sternal reentry for pseudoaneurysm of the ascending aorta Ann Thorac Surg 2003;75:1037-1038.[Abstract/Free Full Text]
- Ito K, Yaku H, Shimada Y, Kawata M, Kitamura N. Left ventricular apex venting during deep hypothermia in a case of difficult re-entry into the mediastinum J Cardiovasc Surg (Torino) 2001;42:493-494.[Medline]
- D’Attelis N, Diemont FF, Julia PL, Cardon C, Fabiani JN. 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]
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