Interact CardioVasc Thorac Surg 2009;9:730-732. doi:10.1510/icvts.2009.205179
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Aortic and aneurysmal |
Aneurysmal ascending to descending aorta bypass graft compressing the pulmonary artery
Vidyasagar Kalahastia,*,
Eric E. Rosellib,
Scott D. Flammc and
Richard A. Krasuskia
a Department of Cardiovascular Medicine/Desk J1-5, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
b Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
c Department of Cardiovascular Imaging, Cleveland Clinic, Cleveland, OH, USA
Received 17 February 2009;
received in revised form 30 June 2009;
accepted 6 July 2009
*Corresponding author. Tel.: +1-216-445-7259; fax: +1-216-445-6164.
E-mail address: kalahav{at}ccf.org (V. Kalahasti).
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Abstract
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We describe the first case of aneurysmal degeneration of ascending to descending aortic bypass graft with compression of main pulmonary artery in a young patient who had prior history of interrupted aortic arch. We also outline the value of multimodality imaging in the surgical management of this condition.
Key Words: Interrupted aortic arch; Aneurysmal aortic graft; Pulmonary artery compression
A 36-year-old man with a history of interrupted aortic arch and ascending to descending aortic bypass using a Dacron graft 21 years earlier presented with acute chest pain. Evaluation by computerized tomography (CT) of the chest showed aneurysmal degeneration of the graft measuring 7 cm and he was transferred to Cleveland Clinic for further management. Transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI) of the chest confirmed aneurysmal graft compression of the main pulmonary artery with right ventricular dilatation. True aneurysmal degeneration of a Dacron graft is rare and the combined imaging modalities helped elucidate the pathology and facilitate surgical planning.
CT angiography showed a large aneurysm of the aortic bypass graft and nearly completely interrupted arch between left common carotid and left subclavian arteries (Type B variation) with anomalous origin of the right subclavian artery (Fig. 1a). TTE revealed normal left ventricular function and a dilated right ventricle with mild decrease in systolic function (Video 1). There was compression of the proximal pulmonary artery with increased flow velocity seen on color flow imaging on TTE and this was best visualized on the parasternal short axis view. The peak jet velocity was 5.6 m/s with a peak and mean gradients of 125/78 mmHg (Video 2). MRI revealed a 6.5x5.7 cm in diameter and 8.8 cm in length aneurysm of the Dacron graft with associated severe compression of the proximal main pulmonary artery. The lumen of the compressed segment of the main pulmonary artery measured 4 mm.
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Fig. 1. (a) CT-scan image showing the aneurysmal degeneration of the ascending to descending bypass graft and interrupted aortic arch. (b) Postoperative CT-scan showing completed repair of the ascending aorta, arch and resection of the aneurysmal aortic bypass graft. This also shows reconstructed brachiocephalic limb, right carotid to subclavian bypass and decompressed pulmonary artery.
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Video 1. Apical four-chamber view on transthoracic echocardiography showing a dilated right ventricle with mild dysfunction.
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Video 2. Parasternal short axis view of the pulmonic valve with color flow demonstrating increased flow velocity due to extrinsic compression of the main pulmonary artery by the aneurysmal aortic graft.
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Interrupted arch reconstruction and resection of the aneurysmal graft, was preceded by right common carotid to right subclavian artery bypass. Arch and proximal descending aortic reconstruction was performed via median sternotomy under deep hypothermic circulatory arrest with intermittent antegrade cerebral perfusion via the right axillary artery and separate cannulation of the femoral artery to allow for perfusion of both proximal and distal vascular beds. After separate reconstruction of bilateral carotid arteries, he underwent balloon thrombectomy of the proximal descending aorta and arch reconstruction with a 22-mm woven Dacron graft. The aneurysmal ascending to descending aortic graft was excised leaving a small residual distal stump at the descending aorta (Fig. 2a and b). The postoperative CT-scan showed intact repair of the arch and descending aorta with patent brachiocephalic vessels (Fig. 1b). Postoperative echo showed significant improvement in the gradient across the pulmonic valve to peak and mean of 17/10 mmHg. The histopathology of the resected graft showed that the graft was endothelialized but appeared fibrotic. There was focal disintegration of the graft material. The sections of the aorta showed mild disarray of the smooth muscle cells with mild increase in mucopolysaccharides and fragmentation of the elastic lamellae. Movat stain did not show any evidence of cystic medial degeneration in the native aorta.
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Fig. 2. (a) Intraoperative appearance of the dissected aortic graft along with aortic arch and brachiocephalic reconstruction. (b) Intraoperative appearance of completed repair of the ascending aorta and aortic arch with attached brachiocephalic graft.
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Although aneurysmal degeneration of Dacron grafts has been described [1–3], this is the first reported case of such associated with compression of the pulmonary artery and right ventricular dysfunction. This case also reinforces the preference for constructing ascending to descending bypass with a right-sided and inferior orientation to the graft [4–6]. The diagnosis was confirmed by multimodality imaging which proved to be extremely valuable to delineate the arch branch vessel anatomy and assist surgical planning.
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References
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