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Surgery for pseudoaneurysm of the ascending aorta under moderate hypothermia
© Jung and Lee; licensee BioMed Central Ltd. 2011
Received: 18 August 2011
Accepted: 30 September 2011
Published: 30 September 2011
Pseudoaneurysm of the ascending aorta is a rare complication after cardiac surgery. Particularly, pseudoaneurysm due to postoperative infection in the ascending aorta requires surgical treatment with antibiotics. If a large sized pseudoaneurysm is located at the retrosternal space, then there is a very high risk of massive bleeding from rupture during performance of resternotomy. To avoid this risk, we performed femoro-femoral bypass under moderate hypothermia with transient circulatory arrest, and we report here on the successful result of this case.
Thoracic aortic pseudoaneurysm is a very rare complication after cardiac surgery with an incidence of less than 0.5% . It has been reported that leaking at an aortic cannulation site is the major risk factor of pseudoaneurysm , and deep sternal infection or an increased possibility of suture dehiscence, such as after an ascending aortic dissection, showed the high occurrence of pseudoaneurysm . A simple chest PA can detect widening of the mediastinum if the pseudoaneurysm is large and the diagnosis can be confirmed with chest CT and an echocardiogram.
A 69 years old female patient was hospitalized for dyspnea, which was her chief complaint. The echocardiogram during the visit showed severe mitral stenosis (MVA = 0.8 cm2) and aortic stenosis (AVA = 0.7 cm2). Mild pulmonary hypertension (RVSP = 34 mmHg) and grade I tricuspid regurgitation were also present with a left ventricular ejection fraction of 43%. Left ventricular hypertrophy was present and the left ventricular wall motion was generalized hypokinetic, but no localized wall motion abnormality was found. According to the coronary artery angiogram, there was no stenosis of the coronary artery and the patient had no other significant medical history except for treatment for hypertension.
During the surgery, the aortic valve and mitral valve were replaced with Hancock® II (Medtronic) 23 mm and Hancock II (Medtronic) 27 mm, respectively, and then no postoperative complications were observed.
With its high risk of rupture, a pseudoaneurysm requires an immediate operation when diagnosed due to the high mortality rate. Despite the recent reports of percutaneously excluding false aneurysms, surgery is still necessary for most cases . An ascending aortic pseudoaneurysm has high morbidity and the mortality rate has ranged from 29%-46% in the medical literature , and this is due to fatal bleeding from rupture of a pseudoaneurysm upon sternal reentry . If a pseudoaneurysm is large and it is located anteriorly and it has eroded into the outer sternum, then there is a very high risk of massive hemorrhage during the surgery . The ascending aortic pseudoaneurysm mainly bulges anteriorly while eroding the boney structures of the sternum. Although rarely reported, ascending aortic pseudoaneurysm can occur posteriorly from an injury caused by a cardioplegia cannula .
The most important part of the surgery is to avoid bleeding during resternotomy and to maintain proper cerebral perfusion . Before resternotomy, carotid artery cannulation is performed for CPB, but femoro-femoral bypass and deep hypothermia have been widely used with satisfactory results . Although the cannulation method can vary according to the size and the location of the ascending aortic pseudoaneurysm, femoro-femoral bypass and deep hypothermic circulatory arrest have high variability for the circulatory arrest time depending on the severity of adhesion, the size of the pseudoaneurysm and the size of the leak .
We think that various methods will continue to be tried to reduce the neurologic complications following circulatory arrest. For this case, aortic cross-clamping was determined to be possible on the distal ascending aorta; subsequently, ascending aorta graft interposition was performed under moderate hypothermia with transient circulatory arrest.
Edwin et al  emphasized ways to prevent postoperative pseudoaneurysm with performing proper suture technique, careful handling of the aorta wall, strict asepsis and aggressive treatment of perioperative infection.
If a large sized pseudoaneurysm is located at the retrosternal space, then there is a very high risk of massive bleeding from rupture during performance of resternotomy. To avoid this risk, we performed femoro-femoral bypass under moderate hypothermia with transient circulatory arrest, and we report here on the successful result of this case.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
This research was supported by Yeungnam University research grants (209A061067) in 2009.
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