Repair of aortic false aneurysm using deep hypothermia and circulatory arrest

doi:10.1016/j.athoracsur.2004.01.028

The Annals of Thoracic Surgery

Volume 78, Issue 1, July 2004, Pages 117-120

https://doi.org/10.1016/j.athoracsur.2004.01.028 Get rights and content

Abstract

Background

Aortic false aneurysms are a rare complication of surgery of the aorta that can occur several months to years after the initial operation. We reviewed our results with false aneurysm repair using deep hypothermia and circulatory arrest.

Methods

Eleven patients were reoperated on for false aneurysm of either the ascending or descending thoracic aorta. Femorofemoral cardiopulmonary bypass with full-dose aprotinin and a heparinized system was used in all patients. Hypothermic circulatory arrest at an average of 20°C was instituted in all patients for repair. Six patients had a patch repair with either polyethylene terephthalate fiber (Dacron) or bovine pericardium, 4 had tube replacement of the aorta, and 1 had primary repair of the defect.

Results

Three patients had false aneurysm formation at a site of coarctation repair in the descending aorta, and the 8 others had false aneurysms in the ascending aorta at the site of a previous aortotomy. Six patients had proven infection as the cause; the causative agent was Staphylococcus species in all cases. Mean cardiopulmonary bypass time was 178 ± 51 minutes, and circulatory arrest time averaged 39 ± 18 minutes. Operative mortality was 18% (2 of 11); the cause of death was cardiogenic shock in both patients. The mean time to extubation in survivors was 5 days, and the average time to discharge was 16 days.

Conclusions

Although mediastinal infection is a common cause, aortic false aneurysms can be safely approached using femorofemoral cardiopulmonary bypass, hypothermic circulatory arrest, and patch repair with acceptable operative mortality and long-term survival.

Section snippets

Material and methods

Patient records were retrospectively reviewed for reoperations for false aneurysm of the thoracic aorta. Patient characteristics are described in Table 1. All patients had a preoperative thoracic computed tomographic scan to better localize the site of aneurysm formation and transesophageal echocardiography for detection of aortic valve insufficiency. The cause of false aneurysm formation was previous surgery in all cases. No aneurysms had ruptured before operation.

Patients with aneurysm of the

Results

From December 1989 to January 2003, 11 patients were reoperated on for false aneurysm of either the ascending aorta in 8 patients or descending aorta in 3 patients. All were emergency operations. False aneurysms in the ascending aorta arose at the proximal anastomosis of a Bentall repair in 3 patients, the proximal anastomosis of an aortocoronary bypass in 3 patients, and the aortic anastomosis of cardiac transplant in 2 patients. In the descending aorta, false aneurysms arose at the proximal

Comment

False aneurysms of the thoracic aorta are a rare complication after surgical manipulation that can appear at sites of anastomosis or cannulation, or at sites of needle puncture for pressure measurements, to purge the aorta of air, or to inject cardioplegic solutions 1, 2, 3. They present a surgical challenge and are usually diagnosed by computed tomographic scans of the thorax or angiography (Fig 1, Fig 2). Once the diagnosis is made, they are considered surgical emergencies and must be

References (9)

T. Katsumata et al.
Mediastinal false aneurysm after thoracic surgery
Ann Thorac Surg
(2000)
A.J. Fillmore et al.
Surgical mortality in patients with infected aortic aneurysms
J Am Coll Surg
(2003)
S. Talwar et al.
Tuberculous aneurysms of the aorta
J Thorac Cardiovasc Surg
(2003)
M. Roth et al.
Aneurysm formation after patch aortoplasty repair (Vossschulte)reoperation in adults with and without hypothermic circulatory arrest
Ann Thorac Surg
(2002)

There are more references available in the full text version of this article.

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Citation Excerpt :
Regardless of etiology, the mainstay of treatment for mediastinitis is extensive débridement of infected tissue [2]. Pseudoaneurysms are also rare and deadly, occurring after 0.5% of cardiac surgical cases [3], with operative mortality rates of 6.2% to 18% for repair of uncomplicated pseudoaneurysms [3–6]. Rarely, pseudoaneurysms can result from necrotizing mediastinitis.
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Original article: cardiovascularRepair of aortic false aneurysm using deep hypothermia and circulatory arrest

Abstract

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Ann Thorac Surg

J Am Coll Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Original article: cardiovascular
Repair of aortic false aneurysm using deep hypothermia and circulatory arrest