Pseudoaneurysm of the Ascending Aorta following Cardiac Surgery

doi:10.1378/chest.93.1.138

Chest

Volume 93, Issue 1, January 1988, Pages 138-143

https://doi.org/10.1378/chest.93.1.138 Get rights and content

Pseudoaneurysm of the ascending aorta is an unusual and potentially fatal complication of cardiovascular surgery. Most pseudoaneurysms are associated with aortic valve or coronary artery bypass graft surgery and are often mycotic in origin. Chest roentgenography and aortography have been the principle methods of diagnosis. Recently, contrast enhanced computed tomography (CT) has proven to be a useful means of diagnosis, providing a less invasive method of distinguishing pseudoaneurysm from other causes of fever and mediastinal widening in the postoperative cardiovascular patient. Thirty one cases of postoperative pseudoaneurysm of the ascending aorta occurring since 1963 are reviewed, including seven cases from our experience.

Section snippets

Material and Methods

Twenty-four cases of postoperative pseudoaneurysm of the ascending aorta published in English since 1963 were reviewed. Five additional cases were added from Thomas Jefferson University Hospital (TJUH) and two from the Medical College of Pennsylvania (MCP). The location of the pseudoaneurysm (Fig 1), the interval of time from the initial cardiac surgery to the diagnosis of pseudoaneurysm, the type of initial surgery performed, the organism found, if any, the outcome of surgery for aneurysm and

Case 1

A 55-year-old man developed a new diastolic murmur due to aortic regurgitation secondary to infective endocarditis following a dental procedure. The aortic valve was replaced with a Bjork-Shiley prosthesis, and four-vessel coronary artery bypass graft surgery was performed. The patient was febrile postoperatively. One out of six blood cultures demonstrated Staphylococcus epidermidis, felt to be a contaminant, and the fever was attributed to a drug reaction.

Six weeks later, the patient developed

Results

Among the 15 patients who underwent aortic valve surgery, pseudoaneurysm occurred at the aortotomy site in seven, the aortic cannulation site in two, the valvulotomy site in one, aortic vent site in one, a sinus of Valsalva in one, and the site of needle puncture in one patient (Table 1). The origin of the pseudoaneurysm was not clearly defined in two patients. One patient underwent both CABG and aortic valve surgery.

Among the 13 patients who underwent CABG surgery, pseudoaneurysm occurred at

Discussion

Postoperative pseudoaneurysms of the ascending aorta usually occur at sites of aortic wall disruption. During cardiopulmonary bypass, the ascending aorta is usually chosen as a site for cannulation1, 3, 13 and is a potential site for pseudoaneurysm formation. The aortic suture lines made during aortic valve replacement or the CABG insertion site are also potential locations.5, 14, 19 A needle may be inserted into the aorta during surgery for pressure measurements, or to purge the aorta of air,

References (26)

BlackLL et al.
Vascular injury following heart valve replacement
Ann Thorac Surg
(1973)
CampbellGS
Injuries of the thoracic aorta
Am J Surg
(1963)
FlickWF et al.
Aneurysm of aortic cannulation site
J Thorac Cardiovasc Surg
(1971)
EliotRS et al.
False aneurysm of the ascending aorta following needle puncture and cross clamping
J Thorac Cardiovasc Surg
(1964)
MorissetteM et al.
False aneurysm of the ascending aorta presenting as an acute myocardial infarction
Chest
(1981)
WindsorHM et al.
Unusual aneurysms of the root of the aorta
J Thorac Cardiovasc Surg
(1967)
LopezGA et al.
Mycotic aneurysm of ascending aorta due to sarcina lutea
Ann Thorac Surg
(1972)
MulderDG et al.
Mycotic aneurysm of the aortic root and infected prosthetic valve treated by excision and homograft valve replacement
Ann Thorac Surg
(1970)
KoenWJ et al.
Causes of death in aortocoronary bypass surgery: Experience with 1000 patients
Ann Thorac Surg
(1977)
MarxM et al.
The truth about false aneurysm
AJR
(1985)

SalamaFD et al.

Complications of cannulation of the ascending aorta for open heart surgery

Thorax

(1970)

SmithP et al.

Dehiscence of infected aortocoronary vein graft suture lines: cause of late pseudoaneurysm of ascending aorta

Br Heart J

(1983)

SteinerRM et al.

The aorta

The textbook of diagnostic imaging

(1985)

Cited by (177)

Transcatheter Closure of Aortic Root Rupture and Pseudoaneurysm After Surgical Implantation of Transcatheter Valve in Native Mitral Annular Calcification With Concomitant Surgically Implanted Transcatheter Aortic Valve
2023, Structural Heart
Difficult Placement of a Pulmonary Artery Catheter: Stenosis of the Internal Jugular Vein From Previous Cannulation or a Pathologic Cause?
2023, Journal of Cardiothoracic and Vascular Anesthesia
Repair of a gigantic ascending aortic pseudoaneurysm – A challenging approach
2023, Revista Portuguesa de Cardiologia
Aortic pseudoaneurysms can be a potentially fatal, yet rare, complication of heart surgery. Surgery is indicated but is high risk during sternotomy. Therefore, careful planning is required. We report the case of a 57-year-old patient who underwent heart surgery twice in the past and who presented with an ascending aortic pseudoaneurysm. A successful repair of the pseudoaneurysm was performed under deep hypothermia, left ventricular apical venting, periods of circulatory arrest and endoaortic balloon occlusion.
Os pseudoaneurismas da aorta podem ser complicações potencialmente fatais, ainda que raras, da cirurgia cardíaca. A cirurgia é indicada mas tem alto risco durante a esternotomia. Desta forma, é necessário fazer um planeamento cuidadoso. Apresentamos o caso de um doente de 57 anos submetido a duas cirurgias cardíacas e que se apresentava com um pseudoaneurisma da aorta ascendente. A reparação bem-sucedida do pseudoaneurisma foi realizada sob hipotermia profunda, drenagem apical do ventrículo esquerdo, períodos de paragem circulatória e oclusão endoaórtica com balão.
Emergent Endovascular Repair of a Ruptured Ascending Aorta Pseudoaneurysm With Thoracic Aortic Stent Graft
2022, Cardiovascular Revascularization Medicine
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.
Combination of a vascular plug and coiling to treat an ascending aortic pseudoaneurysm following aortic surgery
2022, JTCVS Techniques
Transradial Closure of a Large Ascending Aortic Pseudoaneurysm With a Duct Occluder II – A Case Report
2021, Cardiovascular Revascularization Medicine
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.

View all citing articles on Scopus

Manuscript received January 26; revision accepted July 6.

Reprint requests: Dr. Steiner, Suite 3607, 111 South 11th Street, Philadelphia 19107

View full text

Chest

Pseudoaneurysm of the Ascending Aorta following Cardiac Surgery

Section snippets

Material and Methods

Case 1

Results

Discussion

Ann Thorac Surg

Am J Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Causes of death in aortocoronary bypass surgery: Experience with 1000 patients

Ann Thorac Surg

The truth about false aneurysm

AJR

Complications of cannulation of the ascending aorta for open heart surgery

Thorax

Dehiscence of infected aortocoronary vein graft suture lines: cause of late pseudoaneurysm of ascending aorta

Br Heart J

The aorta

The textbook of diagnostic imaging