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Ann Thorac Surg 2011;91:593-595. doi:10.1016/j.athoracsur.2010.07.041
© 2011 The Society of Thoracic Surgeons
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Case Reports

Life-Threatening Aortic Hemorrhage During Pectus Bar Removal

Marek Jemielity, MD, PhDa, Krystian Pawlak, MD, PhDb, Cezary Piwkowski, MD, PhDb, Wojciech Dyszkiewicz, MD, PhDb,*

a Department of Cardiac Surgery, Poznan University of Medical Sciences, Poznan, Poland
b Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland

Accepted for publication July 9, 2010.

* Address correspondence to Dr Dyszkiewicz, Szamarzewskiego 62, Poznan, 60-569, Poland (Email: thorax{at}usoms.poznan.pl).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
This report presents an unusual case of late, aortic hemorrhage that occurred during the removal of the stabilizing bar 3 years after a Nuss operation. The primary reason for this complication was a rotation of the sternum bar, which caused chronic damage to the aorta and development of an aortomediastinal fistula. Cardiopulmonary bypass and implantation of an aortic prosthesis were required for successful treatment of this complication.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Since the 1980s, the Nuss method has been widely used in the repair of pectus excavatum [1]. Metallic bars implanted substernally are well tolerated by patients, the degree of correction is satisfactory, and most importantly, postoperative complications are rare and unusual and rarely endanger the patient's life [2–7]. However, there have been several reports of severe, intraoperative damage to the heart and great vessels caused by the bar insertion [6–9]. This report presents an unusual case of late, aortic hemorrhage that occurred during the removal of the stabilizing bars 3 years after a Nuss operation.

In August 2006, a 15-year-old girl was admitted to the Thoracic Surgery Clinic for Nuss repair of a pectus excavatum. A chest wall deformity, progressing with time, was diagnosed when she was 6 years old. On admission, the patient had the typical, cosmetic complaints and slightly reduced tolerance to physical exercise. Medical and laboratory examinations did not reveal abnormalities other than mild, thoracic scoliosis.

Under videothoracoscopic guidance, a typical Nuss procedure was completed during which 2 surgical steel bars were used for correction of the deformity. The ends of the bars were fixed to the ribs with nonabsorbable stitches and additionally stabilized by small crossbars on the opposite side to prevent rotation.

The patient's postoperative period was uncomplicated. A control roentgenogram showed the chest bars were well positioned, and no pathologic changes were found in the lung and pleura. She was systematically followed-up every 3 months. The 6-month postoperative x-ray image of the chest revealed half-rotation of the upper bar. Because of the good cosmetic result and stable correction of the thoracic deformity, the patient and her parents were unable to decide about further surgical interventions. Later roentgenograms of the chest showed no further rotation of the upper bar and a stable, well corrected sternum. There was no pleural effusion or mediastinal enlargement. The general condition of the patient was excellent.

In September 2009 the patient, now 18 years old, was readmitted for removal of the steel bars. After routine examinations, no changes were found compared with previous clinical and radiologic investigations. General anesthesia was initiated, and the upper bar was released from the scar tissue and removed. Immediately afterwards, a severe hemorrhage occurred from both skin incisions. Fortunately, blood loss (approximately 1500 mL) stopped within a few seconds.

Intensive fluid infusion and the use of catecholamines restored blood pressure to 100 mm Hg and enabled us to continue the operation. To avoid removal of the lower bar at that particular moment, and because we suspected aortic disruption, we performed a left thoracotomy instead of a sternotomy. No blood was found in the left or right pleura. The ascending aorta was firmly attached to the sternum, suggesting a chronic inflammatory process. The lower bar was then removed.

A spiral computed tomography scan of the chest and transesophageal echocardiography were used to establish the exact site of the bleeding and confirmed the presence of an aortomediastinal fistula as the source of the extensive hemorrhage. Cardiopulmonary bypass was initiated using inguinal approach to the femoral artery and a partial (lower) sternotomy to the right atrium. After deep hypothermia circulatory arrest (18°C), the sternotomy was completed, revealing a large, aortomediastinal fistula (Fig 1).


Figure 1
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  		Fig 1. An intraoperative view shows the aortomediastinal fistula during removal of the pectus bar.

 
The ascending aorta was cross-clamped, and after cardioplegic infusion directly to the coronary arteries, the fistula was excised. The blood flow was restored by an end-to-end anastomosis of a vascular prosthesis and the aortic wall. Weaning from the cardiopulmonary bypass went well, and the patient was admitted to the intensive care unit in stable condition.

She was discharged from the hospital 10 days after the operation and started rehabilitation. The patient was able to return to school 3 weeks later. She is systematically being monitored in the outpatient clinic. Three months after this almost fatal complication, her psychologic and physical status remains stable and good.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Postoperative complications after the Nuss procedure are reported to be between 9% and 16% [2, 3, 6]. The most frequent complications are pneumothorax (7%), pleural effusion (2.5%), and displacement or rotation of bars [3, 6]. Only a few of these patients have required surgical intervention. Life-threatening complications of the Nuss procedure, such as damage to the heart or great vessels, are extremely rare and occur intraoperatively, or in the early postoperative period, allowing immediate surgical repair [6–8]. However, one of these reported complications was lethal [5].

Removal of the stabilizing bars, which is the second step in the Nuss procedure, is thought to be a very safe surgical maneuver. We found one case report of nearly fatal bleeding due to cardiac laceration [8]. In this report, we present a life-threatening hemorrhage from the ascending aorta caused by the removal of the steel bars after the Nuss procedure.

The damage to the ascending aorta probably resulted from a persistent pressure of the rotated bar situated as it was between the aortic wall and the sternum (Fig 2). Steady and long-lasting pressure of the edge of the bar had caused chronic rupture of the aortic wall, initiating the development of an aortomediastinal fistula (Fig 3). Removal of the bar opened the fistula, resulting in a severe hemorrhage. The large amount of surrounding scar tissue temporarily closed the fistula, which prevented a catastrophic hemorrhage and enabled us to perform a successful surgical repair. Despite our experience with more than 700 Nuss operations, we have learned lessons from this case, which have led us to the following conclusions:


Figure 2
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  		Fig 2. The lateral roentgenogram of the chest shows the rotated bar as a possible cause of aortic wall rupture.

 

Figure 3
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  		Fig 3. The computed tomography scan with contrast of the chest shows an extravasation of the dye from the anterior aortic wall (arrows).

 
• the rotation of a pectus bar requires a precise assessment of its position in relation to ascending aorta, and
• in case of any doubt, echocardiography or, better, spiral computed tomography, is recommended before removal of these bars.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Nuss D. Minimally invasive surgical repair of pectus excavatum Semin Pediatr Surg 2008;17:209-217.[Medline]
  2. Pilegaard HK, Licht PB. Early results following the Nuss operation for pectus excavatum—a single-institution experience of 383 patients Interact Cardiovasc Thorac Surg 2008;7:54-57.[Abstract/Free Full Text]
  3. Protopapas AD, Athanasiou T. Peri-operative data on the Nuss procedure in children with pectus excavatum: independent survey of the first 20 years' data J Cardiothorac Surg 2008;4:403.
  4. Croitoru DP, Kelly Jr RE, Goretsky MJ, Gustin T, Keever R, Nuss D. The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients J Pediatr Surg 2005;40:181-186.[Medline]
  5. Gips H, Zaitsev K, Hiss J. Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature Pediatr Surg Int 2008;24:617-620.[Medline]
  6. Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications J Pediatr Surg 2004;39:391-395.[Medline]
  7. Hoel TN, Rein KA, Svennevig JL. A life-threatening complication of the Nuss procedure for pectus excavatum Ann Thorac Surg 2006;81:370-372.[Abstract/Free Full Text]
  8. Haecker FM, Berberich T, Mayr J, Gambazzi F. Near-fatal bleeding after transmyocardial ventricle lesion during removal of the pectus bar after the Nuss procedure J Thorac Cardiovasc Surg 2009;138:1240-1241.[Free Full Text]



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This Article
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Wojciech Dyszkiewicz
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