A simple trick for repairing coronary pseudoaneurysm complicating a Bentall operation

Occurrence of pseudoaneurysm of the coronary button due to aortic remodeling after Bentall operation

Here, we present a case report detailing a pseudoaneurysm of the coronary button due to aortic remodeling that occurred 2 years after aortic root replacement. The patient was referred to our hospital with a diagnosis of left coronary artery pseudoaneurysm. Intraoperative findings revealed substantially loosened sutures in both the left and right coronary arteries with bleeding. Specifically, the left coronary artery was detached at the 6-9 o'clock positions. The operation was concluded with ligation of the loose suture and addition of a new suture. Chronic dissection thickened the aortic wall of the coronary artery ostium in the initial Bentall operation, whereas the sutured coronary button in this operation exhibited a normal arterial wall without a thickened dissected intima. This suggests that aortic wall remodelling of the coronary ostium leads to suture loosening and subsequent haemorrhage. Aortic wall remodeling may lead to bleeding or pseudoaneurysms during the remote period.

Transarterial coil embolization of an aortic root pseudoaneurym in a patient with Loeys-Dietz syndrome: a case report

BACKGROUND

Loeys-Dietz syndrome (LDS) is a rare autosomal-dominant connective tissue disorder characterized by arterial aneurysms and vascular friability. Surgical intervention for LDS patients carries significant morbidity and mortality. Currently, the standard management of aortic root pseudoaneurysms is surgical intervention.

CASE PRESENTATION

A 20 year old male with LDS presented with a progressively enlarging ascending aortic aneurysm. He underwent a Bentall-type aortic root replacement complicated by a 20 mm aortic root anastomotic pseudoaneurysm. Due to the patient's high risk for repeat surgical intervention, he underwent successful transarterial coil embolization of his aortic root pseudoaneurysm without complication.

CONCLUSIONS

Coil embolization may provide an alternative treatment for patients presenting with aortic root pseudoaneurysm who are high risk for traditional surgical treatment, such as those with connective tissue disease.

Management of Ruptured Left Ventricular Outflow Tract

Left ventricular outflow tract pseudoaneurysm is a potentially fatal complication after aortic root replacement. Challenges surrounding multiple reoperations on the aortic root include sternal reentry, bleeding, valve positioning, compression of coronary arteries, and navigating concomitant interventions. We present a 27-year-old patient with mechanical valves in the aortic and mitral positions and a left main coronary artery drug-eluting stent for left main compression after being diagnosed with rheumatic heart disease at age 16. She underwent a fourth redo modified Bentall procedure with a homemade mechanical composite graft for the contained rupture of an left ventricular outflow tract pseudoaneurysm.

Percutaneous treatment of late complications of the Bentall procedure

Aortic pseudo-aneurysm following the Bentall procedure is a rare but potentially severe complication. Surgical reintervention represents a high risk. We report on two cases with different pseudo-aneurysm types which were successfully treated using two different percutaneous techniques. © 2017 Wiley Periodicals, Inc.

Aortic Root Replacement for Pseudoaneurysm Arising from Freestyle Aortic Bioprosthesis

A 70-year-old female presented with a new systolic murmur and shortness of breath three years after undergoing aortic root replacement using a 27-mm Medtronic Freestyle® stentless full root bioprosthesis (Medtronic, Inc., Fridley, Minnesota, USA). A large complex aortic root pseudoaneurysm was identified on contrasted computed tomography of the chest and transesophageal echocardiogram. We describe the redo aortic root replacement using a customized Dacron tube/valve composite graft with a proximal "skirt" and a modified Cabrol technique.

[A revised modified bentall's procedure using aorto-prosthetic hemostatic suture]

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Reoperations for aortic false aneurysms after cardiac surgery

BACKGROUND

Aortic false aneurysm is a rare complication after cardiac surgery. Aortic dissection, infection, arterial wall degeneration, and poor surgical technique are recognized as risk factors for the occurrence of postsurgical false aneurysm. Despite some recent reports about percutaneous false aneurysm exclusion, a complex surgical reoperation is needed in most of the cases.

METHODS

We retrospectively reviewed our experience in 43 patients who received a reoperation for postsurgical aortic false aneurysm in the last 14 years. Thirty-three patients were male. The mean age was 60 ± 12 years. Most of the patients received prior aortic surgery on the aortic root, the ascending aorta, the aortic arch, and the descending thoracic aorta (38 patients). False aneurysm was diagnosed during follow-up evaluation in the absence of any symptoms in 23 cases. Univariate and multivariate analyses on 18 perioperative variables were performed.

RESULTS

In-hospital mortality was 6.9% (3 patients). The postoperative course was complicated in 17 cases (39%). At multivariate analysis, a preoperative history of coronary artery disease and postoperative sepsis were independent risk factors for hospital mortality. Survival rates at 1, 5, and 10 years were 94%, 79%, and 68%, respectively. Freedom from reoperation was 86% at 1 year and 72% at 5 and 10 years.

CONCLUSIONS

Despite a high postoperative complication rate, a reoperation for postsurgical aortic false aneurysm can be performed with acceptable mortality and good mid-term and long-term outcomes.

A safe option to perform an apparent difficult redo surgery

A 50-year-old female operated of Bentall five years before was referred to our hospital for an aneurysm of both right subclavian artery and brachiocephalic trunk associated with a false anastomotic aneurysm on the insertion of the left coronary artery. The procedure was performed under moderate hypothermic circulatory arrest; the false aneurysm was repaired, the brachiocephalic trunk and the subclavian aneurysm were resected, an aorto-carotid and axillary bypass were finally performed. The postoperative course was uneventful. She was discharged to home on postoperative day 7. At six-month follow-up, she was still asymptomatic.

Surgical treatment of pseudoaneurysm of the thoracic aorta

OBJECTIVES

To examine the clinical profiles, operative outcomes, and late results of patients with pseudoaneurysm of the thoracic aorta.

METHODS

From 1990 to 2002, 60 patients underwent repair of aortic pseudoaneurysm: ascending aorta in 70%, ascending aorta and arch in 15%, descending aorta in 10%, and arch alone in 5%. Mean age was 53 +/- 15 years, and 70% were men. Of these, 50 (83%) had undergone previous cardiac surgery, including 22 (37%) composite valve graft operations. The preferred cannulation site was femoral-femoral (n = 27, 45%), with deep hypothermic circulatory arrest in 62% and retrograde cerebral perfusion in 33%; more recently, however, axillary cannulation has been preferred.

RESULTS

Principal etiologies were graft infection in ascending aorta pseudoaneurysm and trauma in descending aorta pseudoaneurysm. Fifteen patients (25%) presented with chest pain, 13 (22%) with heart failure, and 20% with moderate or severe aortic regurgitation. The pseudoaneurysm was resected and the aorta replaced (n = 45, 75%) or repaired (n = 15, 25%) using various methods. Hospital mortality was 6.7% (n = 4). Reexploration for bleeding was required in 8.3%, and 3.3% had postoperative stroke. At 30 days, 5 years, and 10 years, survival was 94%, 74%, and 60% and freedom from reoperation was 95%, 77%, and 67%, respectively.

CONCLUSIONS

Most patients with aortic pseudoaneurysm require ascending aorta and/or arch replacement, which can be accomplished with low operative mortality and morbidity. Long-term survival and freedom from reoperation in these young patients parallel those expected for complex cardiac and aortic disease.

Operative Management of Ascending Aortic Dissections

Surgical management has been the established standard of care for acute ascending aortic dissection (Stanford type A or Debakey type I or II) with a worldwide average operative mortality rate of 23% compared with a 1-month mortality rate of 60% with medical management alone. Improving an institution's operative results depends on the establishment of a comprehensive and specialized team integrating their expertise into a protocol-driven system of care delivery specific for aortic dissections. The operative strategies and techniques for repairing aortic dissections should also be standardized within an institution to optimize outcomes. The primary goals of operative repair of ascending aortic dissection are to restore aortic valvular competency and systemic perfusion, to obliterate false-lumen blood flow, and to prevent rupture, myocardial infarction, stroke, and death. The goals, strategies, and expected outcomes for the operative management of acute ascending aortic dissection are presented.