Ann Thorac Surg 2008;85:639-641. doi:10.1016/j.athoracsur.2007.08.028
© 2008 The Society of Thoracic Surgeons
Case Reports
Dilatation of the Aneurysmal Sac After Total Arch Replacement
Hirotaka Watanuki, MDa,
Hitoshi Ogino, MDa,*,
Hitoshi Matsuda, MDa,
Kenji Minatoya, MDa,
Hiroaki Sasaki, MDa,
Tetsuya Fukuda, MDb,
Soichiro Kitamura, MDa
a Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan
b Department of Radiology, National Cardiovascular Center, Suita, Osaka, Japan
Accepted for publication August 14, 2007.
* Address correspondence to Dr Ogino, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan (Email: hogino{at}hsp.ncvc.go.jp).
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Abstract
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In our institution, total arch replacement for distal arch aneurysms is performed through a median sternotomy with antegrade selective cerebral perfusion. The distal anastomosis to the completely transected descending aorta is made through the aneurysmal sac. We report on three interesting cases presenting late dilatation of the aneurysmal sac due to collateral flow after total arch replacement.
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Introduction
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In general, prosthetic graft replacement of aortic aneurysm is carried out without complete resection of the aneurysmal sac. In particular, total arch replacement for distal or proximal descending aortic aneurysm is performed through the aneurysm sac without resection of the aneurysmal wall to prevent injury to the phrenic and vagus nerves and to the lung. In this report, we present three interesting cases that developed late dilatation of the aneurysmal sac after total arch replacement for a distal arch aneurysm through a median sternotomy.
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Case Reports
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Patient 1
An 82-year-old man underwent total arch replacement for a huge saccular-type distal arch aneurysm of 94 mm in 2002. The postoperative course was uneventful. One year later, the follow-up enhanced computed tomographic scans revealed a small leakage of the contrast medium around the prosthetic graft (Fig 1). The leak was considered from the distal anastomosis site. Therefore, stent graft insertion was performed to cover the leak; however, even after this was performed the leak did not disappear. Angiography was then performed to identify some collateral vessels opening into the aneurysmal sac. A collateral vessel originating from the right internal thoracic artery (ITA) to the aneurysm sac was opacified. Coil embolization of the right ITA was then performed. Thereafter, the leak decreased, although it did not vanish completely. The aneurysm sac had not dilated 36 months after coil embolization.
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Fig 1. Enhanced computed tomographic scans for (A) patient 1, (B) patient 2, and (C) patient 3 showing leakage of contrast medium around the artificial graft and inflow of contrast medium to the aneurysm wall.
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Patient 2
An 82-year-old woman underwent total arch replacement for a saccular-type distal arch aneurysm of 60 mm in 2002. The postoperative course was uneventful. One year later, the follow-up enhanced computed tomographic scans revealed some leak of contrast medium into the aneurysmal sac (Fig 1). Although angiography did not reveal any leakage from the distal anastomosis site, a collateral vessel originating from the left ITA to the aneurysmal sac was opacified. Coil embolization of the left ITA was performed. The leak of contrast medium to the aneurysmal sac did not completely vanish. However, the aneurysmal sac was not dilated 41 months after coil embolization.
Patient 3
A 75-year-old man underwent total arch replacement for a huge fusiform type distal arch aneurysm of 100 mm in 2001. The postoperative course was uneventful. Five years later, hemoptysis developed in the patient. Computed tomographic scans revealed a small dilatation of the aneurysmal sac (Fig 1). Although angiography did not reveal leakage from the distal anastomosis site, a collateral vessel originating from the left ITA to the aneurysmal sac was revealed (Fig 2). After coil embolization of the left ITA was performed (Fig 2), hemoptysis disappeared. The patient continues to be carefully followed.
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Fig 2. Angiography of patient 3. (A) Inflow of contrast medium from the left internal thoracic artery (ITA) to the aneurysm wall (B) after coil embolization for the left ITA branch.
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Comment
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Pseudoaneurysm formation after thoracic aortic replacement develops in the late stage. Although it can be secondary to trauma or infection, previous cardiac surgery is the most frequent cause [1]. It occurs in less than 0.5% of all cardiac surgical cases [2]. Pseudoaneurysms are located at previous anastomotic sites, aortotomy sites, cannulation and venting sites, and proximal vein graft anastomotic sites. Anastomotic pseudoaneurysm after ascending or aortic arch replacement for aortic dissection has been reported at various rates ranging from 2% [3] to 38% [4]. It is usually caused by anastomotic leak or cutting of the aortic tissue. In the presented series, the residual aneurysmal sacs dilated after total arch replacement, although in most cases they shrink after surgery. Several causes were considered for these phenomena. Obviously they might be caused by anastomotic leak or cutting of the aortic tissue. However, angiography did not reveal any leak from the anastomotic sites. Even after stent grafting that covering the anastomotic sites, some leakage remained.
In our surgical techniques of total arch replacement for distal arch aneurysm, distal anastomosis is made by division of the descending aorta at the distal site of the aneurysm. The aneurysm is not resected. Some arteries opening into the aneurysm are closed by suturing. However, some of them might be disguised with mural thrombi or atheroma in the aneurysmal sac, because all mural thrombi or atheroma were not always removed in our routine techniques. Thus, the aneurysm sac might be enhanced and dilated. It might have a similar mechanism to that of type II endoleak after endovascular aortic repair. Gould and colleagues [5] reported there were 20% type II endoleaks with preoperative coil embolization for aortic side branches and 23.3% type II endoleaks without preoperative coil embolization during the follow-up period. Therefore, coil embolization was performed to occlude the collateral vessels. There are two similar reports on coil embolization of an aortic arch false aneurysm [6, 7]. Miguel and colleagues [6] succeeded in coil embolization of a pseudoaneurysm over the distal suture line of an ascending aortic graft replacement. Chapot and colleagues [7] succeeded in coil embolization of a pseudoaneurysm at the level of the aortic arch after surgical replacement of the aortic root and arch for aortic dissection. However, in our cases, coil embolization was successful in only 1 patient, presumably because there might be many collateral sources opening into the aneurysmal sac.
Otherwise, systemic pressure has recently been revealed within the aneurysm sacs of patients with collateral endoleak. This discovery suggests that these patients could remain unprotected and at risk for aneurysm rupture [8]. Consequently, close observation for a long period is mandatory even after successful total arch replacement.
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References
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- Sullivan KL, Steiner RM, Smullens SN, et al. Pseudoaneurysm of the ascending aorta following cardiac surgery Chest 1988;93:138-143.[Medline]
- Katsumata T, Moorjani N, Vaccari G, et al. Mediastinal false aneurysm after thoracic aortic surgery Ann Thorac Surg 2000;70:547-552.[Abstract/Free Full Text]
- Bachet J, Termignon JL, Goudot B, et al. Late reoperations in patients with aortic dissection J Cardovasc Surg 1994;9:740-747.
- Sako H, Hadama T, Mori Y, et al. Factors affecting the occurrence of anastomotic leakage after graft replacement of type A aortic dissection [in Japanese] Nippon Kyobu Geka Gakkai Zassi 1995;43:1736-1740.
- Gould DA, McWilliams R, Edwars RD, et al. Aortic side branch embolization before endovascular aneurysm repair: incidence of type II endoleak J Vasc Interv Radiol 2001;12:337-341.[Medline]
- Miguel B, Camilleri L, Gabrillargues J, et al. Coil embolization of a false aneurysm with aorto-cutaneous fistula after prosthetic graft replacement of the ascending aorta Eur J Radiol 2000;34:57-59.[Medline]
- Chapot R, Aymard A, Saint-Maurice JP, et al. Coil embolization of an aortic arch false aneurysm J Endovasc Ther 2002;9:922-925.[Medline]
- Baum RA, Carpenter JP, Golden MA, et al. Treatment of type II endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques J Vasc Surg 2002;35:23-29.[Medline]
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Abstract
Introduction
