Interactive Cardiovascular and Thoracic Surgery 2:385-386(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Punch-hole aneurysm of the ascending aorta after coronary artery bypass surgery
Jens Wippermann*,
Johannes M. Albes,
Harald Brandes and
Thorsten Wahlers
Department of Cardiothoracic and Vascular Surgery, University Hospital Jena, Bachstraße 18, 07743 Jena, Germany
* Corresponding author. Tel.: +49-3641-933-434; fax: +49-3641-934-802
jens.wippermann{at}med.uni-jena.de
Received March 23, 2003;
received in revised form April 16, 2003;
accepted May 1, 2003
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Abstract
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This report describes the case of a 60-year-old man, who developed a giant punch-hole aneurysm of the ascending aorta five month after uncomplicated coronary artery bypass grafting (CABG) due to a localized rupture of the ascending aorta. The patient underwent surgical repair with cardiopulmonary bypass. Because the false aneurysm was adherent to the sternum, resternotomy was performed in deep hypothermia and circulatory arrest. The lesion in the ascending aorta was closed by means of a dacron-patch. The postoperative course of the patient was completely uneventful. We recommend to repair a false aneurysm of the ascending aorta in deep hypothermic circulatory arrest (DHCA) in order to avoid excessive bloodloss during sternotomy.
Key Words: Punch-hole aneurysm; Deep hypothermic circulatory arrest; Coronary artery bypass surgery
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1. Introduction
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The development of a punch-hole aneurysm of the ascending aorta is a rare complication after coronary artery bypass grafting, especially if the origin is a vein graft. To our knowledge this has only been reported in the literature once before [1].
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2. Case report
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Five month prior to admission, a 60-year-old male (164 cm, 76.5 kg) underwent coronary artery bypass grafting at our institution, receiving the left internal thoracic artery (LITA) anastomosed to the left anterior descending artery, one vein graft to the right coronary artery and a second graft to two marginal branches sequentially. The postoperative recovery was completely uneventful. The patient was discharged on postoperative day 16. Three weeks before readmission he complained of recurrent episodes of dyspnoe associated with periods of unspecific chest pain. Physical examination and laboratory findings were unremarkable. A computed tomography scan of the chest, which was indicated by the local physician revealed a giant false aneurysm (6x5 cm diameter) overriding the ascending aorta directly adjacent to the sternum. These findings were confirmed by magnetic resonance tomography (Fig. 1), which also revealed a 3 cm junction between the anterior part of the aorta and the aneurysm. Immediate surgical repair was indicated.
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Fig. 1 Magnetic resonance imaging (sagittal reformation) showing the aneurysm of the ascending aorta located directly behind the sternum.
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3. Surgical technique
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Cardiopulmonary bypass (CPB) was established by cannulating the left femoral vessels and the patient was cooled to 18 °C for subsequent circulatory arrest. Ventricular fibrillation occurred at 28 °C. Because venting was not possible at that time transesophageal echocardiography was instituted to control left ventricular filling. After establishing DHCA, sternotomy was performed using an oscillating saw without damaging the underlying aneurysm. Tissue was divided from the left and right sternal edge, a rib spreader was inserted and the thorax was carefully opened. The aneurysm was dissected from adjacent thymus tissue. The aorta was then prepared cranially to perform aortic cross-clamping. While the aorta was cross-clamped, CPB was reestablished and the aneurysm was incised. An oval opening of 30 mm diameter was found in the anterior aspect of the ascending aorta which originated from the previous punch hole. The patent vein graft to the marginal branches was identified directly below the cranial circumference of the defect (Fig. 2). The aorta was repaired using a 4x2 cm dacron-patch. The bypass ostium was inspected using a dentist's mirror in order to avoid a compromise of the vein graft. After rewarming, the patient was weaned from cardiopulmonary bypass. Cross-clamp time was 47 min while the entire cardiopulmonary bypass time was 137 min. DHCA time was 12 min.
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Fig. 2 Intraoperative photograph demonstrating the opened aneurysm revealing an oval lesion of the ascending aorta, which originated from the punch hole. The overhold-clamp indicates the proximal insertion of the patent vein graft.
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The histopathological examination revealed the typical aspect of a false arterial aneurysm with a thin intimal layer and a fibrous wall with calcified deposits.
The postoperative course was uneventful and the patient was discharged from the hospital in excellent condition 14 days after surgery.
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4. Comment
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This report describes an exceptional case of a giant false aneurysm after coronary surgery. The aneurysm obviously originated from the punched-out opening of the proximal vein graft anastomosis. In the literature, development of false aortic aneurysm after surgery is rare. Degeneration as well as mycotic aneurysm infection have been identified to contribute to this phenomenon [2]. Several reports have documented successful treatment of postoperative aortic aneurysms. Most of them developed after replacement of the ascending aorta and/ or replacement of the aortic valve. They originated mainly from the left coronary sinus or the aortotomy suture line [3–5]. In a retrospective study, Ruchat et al. [1] described an incidence of 0.12% for secondary or so called ‘iatrogenic’ dissections of the ascendens aorta in patients after open heart surgery during the last 20 years. In only five patients the original procedure was CABG. Origination of a false aneurysm from the proximal vein graft anastomosis as observed in the presented case has not been described before. Although there was no disrupted suture line, and the condition of the aortic wall was normal, the culprit lesion for the development of the aneurysm may have been a tear in the aortic wall after punching-out the hole. Fortunately, an abundance of surrounding thymus tissue prevented a free rupture at that time. Thus, we recommend to explore the aorta carefully before a proximal anastomosis is performed especially in arteriosclerotic patients. Surgeons should pay attention to micro-tears after manipulating the ascending aorta during bypass surgery. To repair these rare but potentially fatal complication establishing of CPB via the femoral vessels as well as DHCA are helpful to provide a safe surgical approach, and to avoid excessive bloodloss.
doi:10.1016/S1569-9293(03)00105-1
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References
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Abstract
1. Introduction