Ann Thorac Surg 2009;87:936-939. doi:10.1016/j.athoracsur.2008.07.046
© 2009 The Society of Thoracic Surgeons
Case Reports
Nonmycotic False Aneurysm of Aortic Cannulation Site Presenting 26 Years Postoperatively
Hiroomi Murayama, MD*,
Takashi Watanabe, MD,
Yoriko Kobayashi, MD,
Yasumoto Matsumura, MD,
Atsukata Kobayashi, MD
Department of Thoracic and Cardiovascular Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
Accepted for publication July 16, 2008.
* Address correspondence to Dr Murayama, Department of Thoracic and Cardiovascular Surgery, Toyohashi Municipal Hospital, 50 Hakken-nishi, Aotake-cho, Toyohashi, 441-8570, Japan (Email: romiwo{at}mcn.ne.jp).
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Abstract
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We report the case of a 64-year-old woman who presented with a false aneurysm in the ascending aorta where arterial cannulation was done in an operation 26 years earlier. The aneurysm was excised with the ascending aorta and successfully replaced with a prosthetic graft during deep hypothermic circulatory arrest and retrograde cerebral perfusion, accompanied with concomitant procedures of mitral valve replacement and maze procedure. When the aneurysm, 3.5 x 3.0 x 4.5 cm, was removed, it showed a remarkable sharp line of demarcation between the normal aorta. Microscopic examination of the specimen was consistent with the features of a pseudoaneurysm.
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Introduction
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One of the well-known but uncommon complications of open-heart surgery is false aneurysm at the aortic cannulation site. Most of them are found soon after the operation or at least within several years [1–5]. In this report, we present the case of ascending aortic false aneurysm formed at the site of aortic cannulation 26 years before. No case of this kind has been reported that was diagnosed more than 20 years after a prior operation.
Because of recurrent mitral valve stenosis and recent atrial fibrillation, a 64-year-old woman underwent mitral valve replacement and maze procedure at Toyohashi Municipal Hospital in June 2006. Suffering from rheumatic mitral valve stenosis, she underwent open mitral commissurotomy 26 years ago in 1980. Her uneventful postoperative course was confirmed by clinical records. She had been followed by a local physician for decades and found to be in satisfactory health. She was referred to us again complaining of paroxysmal atrial fibrillation in July 2005. An echocardiogram, as well as continuous wave Doppler examinations, revealed her recurrent mitral valve stenosis. Thus, mitral valve replacement and maze procedure were indicated. A computed tomographic scan, which we routinely use in re-sternotomy cases, incidentally disclosed a 4-cm saccular aneurysm in the ascending aorta (Fig 1). On the basis of the radiographic findings and patient history, a false aneurysm was diagnosed where the aortic cannulation had been made in the prior operation.
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Fig 1. Three-dimensional computed tomographic scan demonstrating a saccular aneurysm (4 cm in diameter) in the ascending aorta where the previous cannulation site was suspected.
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At the operation, full-flow cardiopulmonary bypass was initiated through the femoral vessels, and while keeping the heart beating, core hypothermia was introduced prior to sternal re-entry. During exsanguination of blood back to the pump reservoir together with the pump flow reduced to nearly zero, leading to significant hypotension, re-sternotomy was carried out. There was no evidence of infection in the mediastinum. At the rectal temperature lowered to 18°C, the aortic lesion was excised and replaced with a Dacron graft (Hemashield; Boston Scientific, Natick, MA) during circulatory arrest and retrograde cerebral perfusion. The Cox maze III procedure was performed, and the mitral valve was replaced with a St. Jude Medical valve (St. Jude Medical, St. Paul, MN) during re-warming. The cardiopulmonary bypass was easily discontinued. All cultures and stains for infectious organisms were negative, and the patient recovered uneventfully.
The gross features of the external appearance of the resected aneurysm were saccular (3.5 x 3.0 x 4.5 cm in size) and reddish, similar to the surrounding aortic adventitia. There was a longitudinal scar on the middle of the aneurysm wall, lying parallel to the long axis of the aneurysm. Several ligatures were seen along the scar (Fig 2A). Inspecting the specimen from the luminal side, the orifice of the aneurysm had an oval configuration (measuring 3.0 x 2.0 cm) and showed a sharp demarcation between the normal aorta. No thrombus was observed inside, but a scar remained with ligatures (Fig 2B). These sutured scar findings were consistent with the past technique of cannulation site management in our hospital in which an arterial cannula was introduced into the aorta through concentric 3-0 polyester pursestring sutures by applying the curved vascular clamp tangentially. At the time of decannulation, the vascular clamp was used again, and the pursestring sutures were tied. The aortic incision was reinforced snugly with horizontal mattress 3-0 polyester sutures, which penetrated the full depth of the aortic wall.
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Fig 2. (A) External view, (B) internal view, and (C) low-power photomicrograph (hematoxylin-eosin stain; x25) and (D) high-power photomicrograph (hematoxylin-eosin stain; x150) of the surgical specimen. A sutured scar is seen in the center of the aneurysm. Note the sharp line of demarcation between the aneurysm and normal aortic intima. Photomicrographs clearly show features of a pseudoaneurysm. Several sections of suture filament can be seen (arrows). Scale is in millimeters.
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Microscopic examination of the specimen revealed features consistent with a pseudoaneurysm. The section displays the wall of the aneurysm comprised fibrous connective tissue accompanied with hyaline degeneration deposits. Several sections of suture filament were seen just beneath the border of the inner lumen. The typical arterial arrangement with intima, media, and adventitia was not seen in the aneurysm, whereas the surrounding aorta evidenced nearly normal features (Figs 2C and D).
The patient remains completely asymptomatic with no repeated false aneurysm at 11/2-year follow-up.
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Comment
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Since the first report of Nuñez and Bailey [6] in 1959 and DeWall and Levy [7] in 1963, advocating direct aortic cannulation for cardiopulmonary bypass, this technique has now attained universal acceptance in most cardiovascular surgery centers. The technique offers many distinct advantages, including technical simplicity and superior antegrade perfusion through large bore cannulae, and it is generally considered safer than femoral artery cannulation [1]. However, a rare complication reported was a false aneurysm formed after the aortic cannulation. To date, although several reports of this complication have been available [1–5], the incidence was unclear. In one series, a nonmycotic false aneurysm was found in 1 of 1,760 operative cases [1], and another reported no one affected with this complication in more than 9,000 aortic cannulations [8].
Postoperative false aneurysms are usually noticed by symptoms such as a pulsatile mass in the anterior chest wall or lower neck with a widened superior mediastinal shadow on chest roentgenograms during intervals of several weeks to years [1–5]. They are sometimes accompanied by precordial pain or respiratory symptoms, or both. Otherwise, relatively small ones may be asymptomatic, and such patients, as in our case, possibly go unrecognized for decades. We believe that an aortic cannulation site false aneurysm, incidentally diagnosed more than 20 years after the prior operation, has never been reported. We have no explanation as to when this false aneurysm developed, or as to why over a quarter of a century has passed without recognition. According to the clinical record of the previous surgery, bleeding from the aorta was not evident immediately after the operation, and infection was clearly not a contributing factor.
Nonmycotic false aneurysm at the site of aortic cannulation must be considered, regardless of the time interval from the prior operation. Despite advances in endovascular techniques, we believe that thoracotomy with resection is still the mainstay of therapy. Concerning surgical interventions, although aneurysmectomy and patch repair of the aneurysm orifice were known to be an alternative technique, we used a whole resection of the aneurysm with aorta and tubular replacement with a prosthetic graft. The former is more applicable to aneurysms with a narrow neck, but the latter is universal and may be useful, especially in one with a broad base. We successfully treated the patient suffering from a cannulation site false aneurysm by the techniques of peripheral cannulation, profound hypothermia, and circulatory arrest.
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References
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- Flick WF, Hallermann FJ, Feldt RH, Danielson GK. Aneurysm of aortic cannulation site: successful repair by means of peripheral cannulation, profound hypothermia, and circulatory arrest J Thorac Cardiovasc Surg 1970;61:419-423.
- Branchini B, Zingone B, Vaccari M. Ascending aortic false aneurysm following cannulation for perfusion Thorax 1976;31:234-237.[Abstract/Free Full Text]
- Williams GD, Zimmerman GJ, Osam PN, Daniel MS. False aneurysm of aortic cannulation site occurring three years post-operatively: successful repair with hypothermia and circulatory arrest J Cardiovasc Surg (Torino) 1976;17:266-269.[Medline]
- Soorae AS, Cleland J, O'Kane H. Delayed non-mycotic false aneurysm of ascending aortic cannulation site Thorax 1977;32:743-748.[Abstract/Free Full Text]
- Ramakantan R, Shah P. False aneurysm secondary to aortic cannulation – rupture into lung with fatal hemoptysis during aortography Thorac Cardiovasc Surg 1989;37:322-323.[Medline]
- Nuñez LE, Bailey CP. New method for systemic arterial perfusion in extracorporeal circulation J Thorac Surg 1959;37:707-710.[Medline]
- DeWall RA, Levy MJ. Direct cannulation of the ascending aorta for open-heart surgery J Thorac Cardiovasc Surg 1963;45:496-499.[Medline]
- Taylor PC, Groves LK, Loop FD, Effler DB. Cannulation of the ascending aorta for cardiopulmonary bypass: experience with 9,000 cases J Thorac Cardiovasc Surg 1976;71:255-258.[Abstract]
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Abstract
Introduction
