Mediastinal false aneurysm after thoracic aortic surgery

Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk

Background: The frozen elephant trunk (FET) technique is increasingly utilized for aortic arch replacement in cases of aortic dissections and aneurysms. This rise in usage has led to more patients needing redo aortic surgeries due to progression of existing conditions, FET-related complications, or new valvular/coronary diseases. This article aims to evaluate surgical techniques to minimize risks during these reoperations, including a case study of a complex redo surgery. Methods: A comprehensive examination of surgical strategies was conducted, focusing on preoperative preparation, cannulation site identification, cerebral and cardiac protective measures, and pitfalls to avoid. The importance of adapting to the modified anatomical landscape post-FET is emphasized. A detailed case study of a patient undergoing complex redo FET surgery is included. Results: The article identified key surgical strategies for reoperation in patients with prior FET, highlighting the importance of meticulous preoperative planning and execution. Techniques to minimize risks include detailed imaging for planning, strategic cannulation for optimal perfusion, multidisciplinary approaches as well as careful fail-safe measures. The case study demonstrates the practical application of these strategies in a high-risk scenario. The evidence underscores the necessity for individualized patient management and the development of standardized protocols. Conclusions: The FET technique, while effective for initial aortic arch repairs, often necessitates complex reoperations. Adopting advanced surgical strategies and multidisciplinary planning can significantly mitigate risks associated with these procedures. Future research should focus on refining these techniques and establishing standardized protocols to improve patient outcomes.

Novel modification of a branched arch endograft with a retrograde left common carotid branch for acute pseudoaneurysm post type A repair

OBJECTIVE

Pseudoaneurysm formation post type A aortic dissection repair is rare. Revision surgical repair is challenging, with a risk of death from haemorrhage.

METHODS

We present a 56-year-old man who presented with a rapidly enlarging distal ascending aortic anastomotic pseudoaneurysm following a recent ascending and hemiarch replacement for acute type A aortic dissection.

RESULTS

A tight kink in the ascending aortic graft precluded an endovascular repair utilizing two antegrade branches, and so a novel custom-made 3 inner branched aortic endograft was designed, with an antegrade brachiocephalic inner branch and retrograde left common carotid and subclavian artery inner branches. The patient required an angioplasty to dilate the kinked/coarcted surgical graft, but made an uneventful recovery.

CONCLUSION

An aortic arch inner branch design with an antegrade brachiocephalic branch but retrograde left common carotid and left subclavian branches was feasible and may prove particularly useful when there is limited space in the ascending aorta.

Comprehensive multi-modality treatment of thoracic aorta pseudoaneurysms: a single-center experience

INTRODUCTION

Thoracic aorta false aneurysms (TAFA) are unexplored complications after cardiac surgery associated with significant morbidity and mortality. Therefore, the purpose of this study was to examine the clinical profiles, surgical techniques, and operative outcomes, of patients treated for TAFA at a single institution.

METHODS

From 1996 to 2022, 112 patients were treated for aortic pseudoaneurysm (mean age 55 ± 14 years, 78 patients were male). In the majority of the patients (90%) TAFA developed after previous cardiovascular surgery, the most common diagnosis and surgical procedure preceding the TAFA development was an aortic dissection (52%) and Bentall procedure (47%). In the rest of the cohort, the leading cause was trauma.

RESULTS

Sixty-one percent of patients were indicated for reintervention (surgical reoperation, endoluminal graft implantation, septal occluder implantation, coil embolization, or a combination of procedures). Overall, 52 patients had undergone cardiac reoperation. TAFA was resected and the aorta was repaired in 55% or replaced in 45%. Operative mortality was 5.7%. In postoperative follow-up, a hypoechogenic lesion encircling aortic prosthesis was present in 94%, therefore it was determined as a negative prognostic factor. The mean follow-up was 13.2 ± 19.4 years.

CONCLUSION

Although there is no specific approach how to prevent TAFA development, maintaining normal blood pressure and regular follow-up should be applied. More frequent follow-ups should be performed in patients with a hypoechogenic lesion encircling and aortic prosthesis. Early detection during long-term postoperative follow-up, an individually tailored approach of a multidisciplinary team is necessary for favorable treatment outcomes.

Hybrid extracorporeal cannulation for aortic root pseudoaneurysm re-operation: The role of a multidisciplinary team

Introduction: Adequate cerebral protection for aortic reoperation is challenging and optimal technique is still controversial.Case Report: We report a hybrid cannulation approach to achieve safe cerebral protection during circulatory arrest to repair an aortic root pseudoaneurysm.Conclusion: A multidisciplinary approach combining conventional techniques and interventional expertise could be considered in complex aortic scenario.

Surgery of Neoaortic Pseudoaneurysm with Transsternal Penetration in a HLHS Patient

Background Neoaortic pseudoaneurysm after previous surgery is rare and life-threatening. Case Description We present a case of a 6th redo surgery in a 23-year-old male patient with a history of hypoplastic left heart syndrome presenting with transsternal penetration of aortic pseudoaneurysm. The previously implanted Dacron prosthesis showed semicircular dehiscence. It was exchanged by a Vascutek prosthesis during circulatory arrest and selective antegrade cerebral perfusion. Conclusion Control imaging at 1 year after surgery was unobtrusive. Three years after surgery, the patient is alive and doing well.

False aneurysms of the thoracic aorta: anastomosis investigation using the inflation-extension test

INTRODUCTION

False aneurysms in the thoracic aorta are dangerous complications that can occur after cardiac surgery. They often result in high mortality rates. These aneurysms are caused by damage to all layers of the aortic wall. This study aimed to pinpoint the area of the experimental specimen (native vessel, anastomosis, or prosthetic graft) with the greatest deformation, to determine whether a false aneurysm is likely to develop in the anastomotic portion.

METHODS

We conducted the inflation-extension test by performing eight cycles ranging from 0 to 20. The pressure sampling frequency was 100 Hz, and each cycle lasted approximately 34 seconds, resulting in a loading frequency of 0.03 Hz. During the experiment, each camera captured 3,000 frames. Based on the data collected, we evaluated and compared the loading stages of cycle 1 and cycle 8.

RESULTS AND DISCUSSION

During loading, the native vessel experienced a dominant deformation of approximately 7% in the circumferential direction. The prosthetic graft, which had a longitudinal construction, deformed by approximately 8% in the axial direction. The prosthetic graft, on the other hand, only experienced a deformation of up to 1.5% in the circumferential direction, which was about 5 times smaller than the deformation of the native vessel. The anastomosis area was very stiff and showed minimal deformation. Additionally, there was little difference in the mechanical response between the first C1 and the eighth C8 cycle.

CONCLUSION

Based on the available evidence, it can be inferred that aortic false aneurysms are more likely to form just behind the suture lines in the native aorta, which is more elastic compared to stiff sections of anastomosis and prosthetic graft. Numerous pulsations of the native vessel will likely cause the impairment of the aorta at the margin of the anastomosis. This will lead to disruption of the aortic wall and false aneurysm formation in the native vessel near the area of anastomosis.

Granulomatous inflammation mimicking a hematoma around the replaced ascending aorta in magnetic resonance imaging: a case report

BACKGROUND

Granulomatous inflammation results from various causes including infections and allergic reactions. It can appear as high signal intensity in T2-weighted or contrast-enhanced T1-weighted magnetic resonance imaging (MRI). Here, we describe a case of granulomatous inflammation looking like a hematoma on an ascending aortic graft in MRI.

CASE PRESENTATION

A 75-year-old female was undergoing assessment for chest pain. She had a history of hemi-arch replacement for aortic dissection 10 years earlier. The initial chest computed tomography and subsequent chest MRI were suggestive of a hematoma, implying a pseudoaneurysm of the thoracic aorta, which is associated with high mortality in reoperation. Through redo median sternotomy, severe adhesion was found in the retrosternal space. A sac in the pericardial space contained yellowish and pus-like material, confirming that there was no hematoma around the ascending aortic graft. The pathologic finding was chronic necrotizing granulomatous inflammation. Microbiological tests including polymerase chain reaction analysis were negative.

CONCLUSION

Our experience indicates that an MRI finding of a hematoma at the site long after cardiovascular surgery suggests that there may be granulomatous inflammation.

A giant transsternal aortic pseudoaneurysm

Aortic pseudoaneurysm is a rare but life-threatening complication after a cardiac surgery. Potential mechanisms are suture dehiscence, iatrogenic trauma and poor quality of aortic tissues. Most cases are diagnosed in the first months after the surgery and are due to an infectious process. Here, we report a case of transsternal aortic pseudoaneurysm after an aortic valve replacement surgery and we describe our surgical approach. This case is exceptional for its late timing and presentation with a pulsatile sternal mass.

Abdominal Stent-Graft Treatment of Ascending Aortic Pseudoaneurysm Following Transcatheter Aortic Valve Implantation

An ascending aortic pseudoaneurysm is a potentially lethal complication in aortic procedures. We present a hybrid approach using surgical innominate artery access and the endovascular insertion of an abdominal stent-graft extension to successfully treat a zone 0 ascending aortic pseudoaneurysm in a patient with a prior valve-in-valve transcatheter aortic valve implantation.

Percutaneous closure of a post-surgical ascending aortic pseudoaneurysm with an amplatzer septal occluder device and steerable guiding sheath

Thoracic pseudoaneurysm in the ascending aorta is an uncommon condition associated with significant risk of morbidity and mortality. Treatment is recommended in all cases regardless of symptoms as the mortality rate if left untreated has been documented to be as high as 61%. The current standard of care for managing these lesions is open surgical repair. However, this is associated with significant morbidity. In-hospital mortality reported for patients undergoing surgical repair of an ascending aortic pseudoaneurysm ranges from 6.7% to 41%. When anatomically suitable, a less invasive approach using amplatzer vascular plug or septal occluder is an attractive approach. We present a case report of repair of a post-surgical ascending aortic false aneurysm using an amplatzer septal occluder with an Oscor ™ steerable guiding sheath; a novel approach to increase platform stability when engaging an aneurysm neck. Endovascular occluder deployment for closure of aortic false aneurysms remains a relatively novel technique. It is limited by the requirement to develop a stable endovascular platform to deliver the device and avoid system prolapse, particularly when accessing challenging lesions on the inner aortic curvature. We present the first case to utilize a steerable guiding sheath system to improve system stability and facilitate successful device delivery. Given the significant morbidity associated with open repair of these lesions we hope this will further expand the range of lesions viewed as appropriate for endovascular repair.

Emergent endovascular repair of a ruptured ascending aorta pseudoaneurysm with thoracic aortic stent graft

Pseudoaneurysm of the ascending aorta is a rare complication of cardiac surgery due to tissue degeneration at the site of graft anastomosis, aortotomy, or extracorporeal circulation cannulation. We describe the case of a patient who developed an ascending aorta pseudoaneurysm after coronary artery bypass graft surgery, which initially required percutaneous closure with an atrial septal defect occlusion device. However, three years later the patient presented again with active external bleeding secondary to pseudoaneurysm enlargement and rupture, which was emergently repaired by percutaneous endovascular repair with a thoracic aortic stent graft. At one-year follow-up the patient is in good conditions and asymptomatic.

Percutaneous endovascular management of ascending aortic pseudoaneurysm after heart transplantation in a pediatric patient

Ascending aortic pseudoaneurysm is a rare complication after HT. Surgery is the most conventional management, but in some patients, it is risky. We report the case of a ten-year-old child who underwent HT and developed an ascending aortic pseudoaneurysm in the aortic anastomosis. He was successfully treated with two covered stents through endovascular management. Endovascular therapy is an alternative management in high-risk patients. To our knowledge, this is the first report about endovascular therapy of an AAP after HT in a pediatric patient.

Transradial Closure of a Large Ascending Aortic Pseudoaneurysm With a Duct Occluder II - A Case Report

Pseudoaneurysm of the ascending aorta is a rare but potentially life-threatening complication of cardiothoracic surgery. Re-operation is associated with a high mortality risk; therefore, percutaneous endovascular closure techniques with different closure devices have been repeatedly reported over the last 15 years. Previous endovascular procedures were performed using a transfemoral or transbrachial approach. We report a case of transradial ascending aortic pseudoaneurysm closure in a patient deemed unsuitable for surgery.

Surgical Treatment of Pseudoaneurysm of the Ascending Aorta in a Patient with Sepsis

Pseudoaneurysm of the ascending aorta (PAA) is a hazardous and potentially fatal cardiovascular disease. This condition is caused by the rupture of at least one layer of the vessel and contained by the remaining vascular layers or the surrounding mediastinal structures. We presented the surgical treatment of a patient with sepsis and large PAA and brachiocephalic trunk, which was compressing the brachiocephalic trunk leading to syncope.

Surgical management of a pulsatile chest wall mass secondary to an ascending aortic aneurysm in a patient with bovine arch

Ascending aortic pseudoaneurysms are rare, but life-threatening conditions, that often require intervention. While endovascular techniques have advanced significantly, the majority of these clinical scenarios preclude endovascular options and the primary treatment modality remains open surgical repair. Repair of an aortic pseudoaneurysm eroding through the sternum resulting in a pulsatile chest wall mass is technically challenging. We report the successful repair of a large ascending aortic pseudoaneurysm in a 62-year-old male with bovine arch anatomy and prior Type A dissection repair, presenting with contained rupture and a pulsatile chest wall mass.

Aortic pseudoaneurysm repair after Bentall procedure using the IntraClude device

BACKGROUND

Despite advances in surgical techniques, aortic reoperation is still associated with a high risk of mortality due to possible injury of the myocardium or great vessels during resternotomy.

MATERIALS & METHODS

We report the case of a giant aortic pseudoaneurysm, 17 years after the Bentall procedure in a 76-year-old male patient.

RESULTS

Successful pseudoaneurysm resection after the Bentall procedure using the ThruPort IntraClude intra-aortic occlusion device (Edwards Lifesciences) was achieved.

DISCUSSION

The IntraClude catheter can be used effectively to provide endovascular clamping of the ascending aorta during challenging cardiac reoperations.

Ascending aorta pseudoaneurysm simulating mediastinal lymphoma in computed tomography, a possible diagnostic error: a case report

Background

An ascending aortic pseudoaneurysm is a severe and rare complication following cardiothoracic surgery. This case report demonstrates its possible misinterpretation and the consequent importance of multidisciplinary evaluation.

Case presentation

We present a case of an 18-year-old Caucasian man with Marfan syndrome who developed an ascending aortic pseudoaneurysm about 1 year after undergoing cardiac surgery with the Bentall procedure. Computed tomographic examination of the thoracic aorta and positron emission tomography–computed tomography initially suggested a lymphomatous pathology. However, these imaging results were in contrast to the transesophageal echocardiogram and the laboratory data that showed negative results for hematological pathology. A second computed tomographic scan redirected the diagnosis toward a pseudoaneurysm.

Conclusion

This case demonstrates the utility of close communication and interdisciplinary consultation between cardiovascular radiologists and the cardiac surgery team, which are mandatory in order to maximize their diagnostic skills in identifying postoperative complications.

Lethal recurrent mycotic ascending aortic pseudoaneurysm in a 21-month-old child with repaired subaortic membrane

Mycotic pseudoaneurysm of the aorta is a rare and lethal complication of pediatric congenital heart surgery. We report the lethal consequences of recurrent mycotic pseudoaneurysm in an 18-month-old baby, early after subaortic membrane resection. We managed to repair the pseudoaneurysm successfully by replacing the infected ascending aorta using bovine jugular vein graft, but unfortunately, the patient developed new pseudoaneurysm at the site of anastomosis which led to his death. Although prompt diagnosis and surgical management can save the patient life, uncontrolled infection can lead to the recurrence of the problem and lethal results.

Long-term follow-up after Bentall operation using a stentless Shelhigh NR-2000 bio-conduit

BACKGROUND

To analyze the long-term results after Bentall operation using the stentless Shelhigh No-React (NR)-2000 bio-root prosthesis.

MATERIAL

From 2004 to 2008, 26 consecutive, nonselected patients (mean age at surgery: 67 ± 9 years) underwent a Bentall operation using a stentless Shelhigh valved conduit at our institution. Mean preoperative Logistic-EuroSCORE was 17.1 ± 12.9. The mean size of the aortic root was 53.2 ± 5 mm. The mean preoperative ejection fraction was 55 ± 7.4%. Three patients had a bicuspid valve. One patient with acute endocarditis and one patient with type A aortic dissection were operated on an emergency. Three patients (11.54%) had a previous cardiac operation. The Button-Bentall technique was used in all cases. Seven patients (26.92%) received an associated procedure. The mean size of the implanted prosthesis was 26.1 ± 2.2. Follow-up ranged between 6 and 174 months (mean 93.4 ± 59.1 months). Primary endpoints consisted of early and late mortality, freedom from acute endocarditis, freedom from structural valve deterioration, and freedom from valve-related-reoperation.

RESULTS

Two patients died in hospital, while 10 patients died during follow-up time, of which three for cardiac causes (12.5%). Overall survival probability was 52.9% at 15 years. Freedom from acute endocarditis was 95.7% at 5 and 15 years. Freedom from severe aortic incompetence due to structural deterioration was 100% at 5 and 10 years, 90.9% at 15 years. The mean aortic gradient at follow-up was 11.4 ± 5 mm Hg. Freedom from valve-related reoperation was 100% at 5 and 10 years, 90.9% at 15 years.

CONCLUSIONS

In our experience, Bentall's operation using the Shelhigh NR-2000 stentless bio-conduit provided satisfactory early and long-term results. However, our findings are not consistent with unfavorable long-term outcomes following the implantation of this device reported by other authors.

Infected aortic pseudoaneurysm repair using autologous common femoral artery patch and fascia

Using autologous common femoral artery and external oblique muscle fascia is a simple and reliable option for repairing infected aortic pseudoaneurysms. Reoperation of infected pseudoaneurysms is challenging and requires secure aortic repair with complete infection eradication. Here, we report two cases of infected pseudoaneurysms in the ascending aorta cannulation site after cardiac surgeries. Common femoral arteries and fascia were harvested in the same lesion as repair materials. The aortic pseudoaneurysms were repaired under deep hypothermic circulatory arrest. Femoral arterial patches were reinforced with circumferential aponeurosis strips. There was no infection recurrence or repair site dilatation in the long-term follow up of both patients.

Endovascular Closure of 2 Subannular Pseudoaneurysms of the Aortic Root After Surgical Aortic Valve Replacement

A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded after 10 days and was treated using endovascular closure devices. (Level of Difficulty: Advanced.)

Pseudoaneurysm of the Ascending Aorta at the Cannulation Site Diagnosed More Than Four Decades After Repair of Ventricular Septal Defect

Described herein is a 69-year-old woman who developed a large saccular aortic aneurysm at a previous cannulation site for repair of a ventricular septal defect at age 25 years. The aneurysm was resected and proved histologically to be a false one. The long interval between operations (44 years) exceeds those reported previously.

Hybrid surgical and endovascular repair for anastomotic pseudoaneurysms after total arch replacement

An 83-year-old woman who had undergone total arch replacement for a thoracic aortic aneurysm seven years prior experienced concurrent rupture of second and third branch anastomotic pseudoaneurysms. A stent graft was initially deployed across the pseudoaneurysm from the third branch to the left subclavian artery. Following the left axillary and left carotid arterial bypass, the origin of the second branch was embolized with metallic coils. As a result, both anastomotic pseudoaneurysms were undetectable by both completion angiogram and postoperative CT. By combining surgical and endovascular procedures, ruptured anastomotic pseudoaneurysms after total arch replacement can be repaired without a risky resternotomy.

Transapical Coil Embolization of a Postsurgical Ascending Thoracic Aortic Pseudoaneurysm

Ascending aortic pseudoaneurysms are a rare but potentially life-threatening complication of aortic root or cardiac surgery. Surgical repair is established as first-line treatment; however, patient comorbidities, technical considerations, and anatomic limitations often preclude patients from repeat surgery, thus necessitating alternative approaches. Here, we present a case of coil embolization of an ascending aortic pseudoaneurysm via a transapical approach in a particularly complex scenario where percutaneous and peripheral access was technically unfeasible.

A rare case of late aortic pseudoaneurysm post double valve replacement

Here, we present a case of pseudoaneurysm of the aorta, 2 years after double valve replacement (DVR) in an 18-year-old male patient presented with a pulsatile swelling over the sternum. The pseudoaneurysm of the aorta extending up to the skin 2 years after cardiac surgery is a rare condition. Most cases are asymptomatic and need emergency surgery. Here, we present the case which was successfully managed with surgery.

Reoperation for a giant arch anastomotic pseudoaneurysm eleven years after total arch replacement with island reconstruction

BACKGROUND

The long-term effects of some surgical treatment procedures of arch replacement for aortic dissection or aortic aneurysm are unknown.

CASE PRESENTATION

The present study reports the case of a 68-year-old man admitted to our hospital for aortic arch anastomotic pseudoaneurysm with concomitant aortic root enlargement and coronary artery stenosis. Eleven years ago, at the age of 56 years, he underwent total arch replacement with island reconstruction for chronic aortic dissection. We performed a second total arch replacement, aortic root replacement, and coronary artery bypass, using a cardiopulmonary bypass with cannulation through the right subclavian artery, femoral artery, and femoral vein prior to re-sternotomy. We also used selective cerebral perfusion. Postoperatively, the patient temporarily required reintubation; however, he was discharged in good condition on the fiftieth postoperative day.

CONCLUSIONS

This case suggests that island reconstruction has the potential to cause arch anastomotic pseudoaneurysms, particularly after a long postoperative period.

Keep Ventilating the Lungs While the Heart is Still Ejecting on Femoro-femoral Cardiopulmonary Bypass

Femoro-femoral cardiopulmonary bypass (CPB) followed by deep hypothermic circulatory arrest is one of the modalities used for ascending aortic pseudoaneurysm repair to achieve cardiac unloading and to avoid severe hemorrhage due to the risk of rupture during the sternal entry. However, due to the limited size of the cannulas, it can be challenging to achieve total cardiopulmonary support. Therefore, despite the achievement of total cardiopulmonary support, the heart may still be able to eject antegrade blood flow that meets the retrograde blood flow from the arterial side of the CPB. The point where the blood flow meets in the aorta is called the watershed area. If the antegrade blood flow is large due to a left ventricular ejection, the watershed area will be located in the descending aorta. Therefore, if ventilation is stopped, deoxygenated blood will be ejected to the cerebral circulation. Cerebral near-infrared spectroscopy (NIRS) may be used as a noninvasive and continuous measurement of regional brain oxygen saturation (rSO₂). This case demonstrates that cerebral desaturation due to discontinued mechanical ventilation, when the heart was still ejecting during the initial phase of femoro-femoral CPB, immediately was detected by a pronounced drop bilaterally: In the left frontal lobe, rSO₂ fell from 56% to 21%, and in the right frontal lobe it fell from 47% to 25%. The authors recommend monitoring cerebral saturation using NIRS in the case of femoro-femoral CPB.

Endovascular repair of a leaking aortic-arch pseudoaneurysm using graft stent combined with chimney protection to left common carotid artery: Case report and review of literature

Aortic pseudoaneurysm (PsA) is a rare but serious condition that has high mortality and morbidity rates if untreated. We report a rare case of leaking aortic-arch PsA repaired by thoracic endovascular aortic repair using graft stent with the chimney technique to protect the left common carotid artery. Unlike other cases in the literature, our case was unique, having leaking PsA not related to previous cardiac surgery or aortic dissection. The successful management of this patient using thoracic endovascular aortic repair combined with the chimney technique suggests that this approach may be an attractive therapeutic alternative to treat aortic-arch PsA.

Imaging of the Postsurgical Thoracic Aorta: A State-of-the-Art Review

Techniques for repair of the aorta currently include open and endovascular methods, hybrid approaches, minimally-invasive techniques, and aortic branch vessel reimplantation or bypass. Collaboration among radiologists and vascular and cardiothoracic surgeons is essential. An awareness of the various surgical techniques, expected postoperative appearance, and potential complications is essential for radiologists. This review will cover the postoperative appearance of the thoracic aorta with a focus on the ascending aorta. The value of three-dimensional image evaluation will also be emphasized.

Repair of ascending aortic pseudoaneurysm eroding through the sternum

In reoperation for an ascending aortic pseudoaneurysm eroding through the sternum, a left ventricular vent allows careful unhurried sternal division under deep hypothermic circulatory arrest. We repaired ascending aortic pseudoaneurysms in 2 patients who had undergone aortic valve implantation 6 and 21 months earlier. A minithoracotomy was made in the left 5th intercostal space, and a vent was placed in the left ventricular apex. Repair was accomplished with a bovine pericardial patch reinforced with a Teflon felt strip. Both patients made an uneventful recovery with good functional status at discharge at the 8- and 18-month follow-up.

Bailout Endovascular Stent Grafting for an Ascending Aortic Pseudoaneurysm Using an Infrarenal Aortic Extension Cuff

We report successful thoracic endovascular repair of a pseudoaneurysm rupture in the ascending aorta using infrarenal endovascular devices after an aortic valve replacement. Complete exclusion of the pseudoaneurysm was achieved with no endoleak or postoperative complications. Despite limitations of the current technology, this endovascular technique was a relatively less invasive, feasible lifesaving surgical option for the repair of a pseudoaneurysm of the ascending aorta with a diameter ≤32 mm.

Safe Reentry for False Aneurysm Operations in High-Risk Patients

BACKGROUND

In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients.

METHODS

We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery.

RESULTS

We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years.

CONCLUSIONS

The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Protective effect of angulated aorta for saving coronary artery during endovascular repair for ascending aortic pseudoaneurysm

Ascending aortic pseudoaneurysm is a rare complication after cardiothoracic surgery and the open surgical repair for this complication is challenging. We report on a patient who developed an ascending aortic pseudoaneurysm after aortic valve replacement (AVR), which was treated successfully with endovascular therapy. Our case showed that angulation of the ascending aorta is one of factors for consideration in application of endovascular therapy and endovascular therapy might be an option for management of ascending aortic pathology in patients with high surgical risk, particularly patients with a severely angulated proximal ascending aorta.

Recurrence of Aneurysm of the Ascending Aorta after Patch Repair: The Fate of an Aortic Patch

Pseudoaneurysm of the ascending aorta is a rare but life- threatening complication after aortic cannulation and cardiovascular surgery, and it has the potential to rupture. We experienced a rare case of recurrence of aneurysm of the ascending aorta 7 years after patch repair of a small aneurysm at an aortic cannulation site. The repaired aorta had been wrapped with a Teflon felt strip during the previous surgery, and the wrapped aorta had become thin with deterioration of the normal structure of the aortic wall.

Transesophageal echocardiographic guidance for percutaneous closure of aortic pseudoaneurysm using a type II Amplatzer vascular plug: a case report

Aortic pseudoaneurysm after cardiac surgery is a rare entity, but it is potentially fatal due to its clinical course along with higher morbidity and mortality rates. Instead of open surgical repair, percutaneous procedures have been introduced as other options for managing an aortic pseudoaneurysm. In this case report, we describe transesophageal echocardiography guidance for successful percutaneous closure of an aortic pseudoaneurysm located in the left ventricular outflow tract by using a type II Amplatzer vascular plug in a patient in whom open surgical repair was not recommended.

Pulmonary artery stenosis caused by a large aortic arch pseudoaneurysm detected 10 years after a minor trauma

Pseudoaneurysm of aorta is a rare condition usually seen after aortic surgeries or serious accidents. Here we report a 60 years old man without any previous medical condition who presented with non-specific symptoms and underwent different investigations for more than 1 year, until the presence of a continuous murmur raised suspicion toward his cardiovascular system. In echocardiographic and computed tomography (CT) angiographic studies a large pseudoaneurysm of aortic arch with compression effect on pulmonary artery was detected. At this stage he remembered having suffered a minor trauma 10 years ago. He finally underwent operation and his aortic wall was repaired successfully with a patch. This case highlights the importance of thorough history taking and physical examination in patients irrespective of symptoms and high index of suspicion to detect this life-threatening condition.

Two-Stage Procedure for Infected Aortic Graft Pseudoaneurysm: 10-Year Follow Up after Omental Prosthesis Wrapping

Prosthetic graft infections with mediastinitis following aortic surgery are rare, yet represent grave complications yielding high morbidity and mortality. We present the case of a 57-year-old female patient with past history of emergent surgery for iatrogenic Type A dissection treated by supracoronary ascending aortic replacement. Four months after the initial surgery, a sternal fistula had formed and due to severe bleeding emergent reoperation was required. Imaging and pathology on admission revealed an infected pseudoaneurysm at the distal aortic prosthesis and mediastinitis with methicillin-resistant Staphylococcus aureus. Rescue surgery was performed by means of a two-stage approach, with extensive debridement, graft replacement and continuous antiseptic lavage in a first step and an omental wrapping of the new prosthesis in a second stage 24 hours later. During 10 years of follow-up, no recurrent infection occurred. The operative approach and general considerations for management of infected pseudoaneurysms are discussed.

An apical left ventricular aneurysm rupture presenting as left breast mass 11 years after surgical repair

Left ventricular (LV) pseudoaneurysm is a rare entity and, consequently, there is limited knowledge of the condition's natural history. The most frequent mode of presentation for LV pseudoaneurysm is heart failure with chest pain. However, the variable presentation of this condition requires a high index of suspicion for diagnosis. We report the case of a 75-year-old woman who had suffered an acute myocardial infarction 23 years previously, which resulted in a calcified LV apical aneurysm. Three weeks prior to being referred to our hospital, she was noted by her general practitioner to have a left-sided breast mass although mammography was negative. One week later, she attended the accident and emergency department; she was haemodynamically unstable but was resuscitated successfully. Contrast enhanced computed tomography showed a large haematoma located in the left chest wall communicating with the left ventricle. She underwent emergency cardiac surgical repair. On arrival at the intensive care unit following surgery, her haemodynamic status was unstable, and she deteriorated rapidly and died. With this report, we aim to raise the level of awareness for an apical LV pulsatile mass that could anatomically expand and present as a breast mass or tumour. An early diagnosis and timely surgical intervention is essential in order to achieve better outcomes and avoid detrimental complications.