Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 320-323

Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy


1 Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), New Civil Hospital Campus, Ahmadabad, Gujarat, India
2 Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, Ahmadabad, Gujarat, India

Date of Submission10-Apr-2019
Date of Acceptance24-May-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Devvrat Desai
Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), New Civil Hospital Campus, Ahmadabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_22_19

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  Abstract 


Aneurysm of the distal aortic arch is routinely repaired using left thoracotomy. Here, we are reporting an unusual case of intact giant fusiform aneurysm of the distal aortic arch with managed successfully using midline sternotomy. A 54-year-old gentleman presented with progressive dyspnea and chest pain in the New York Heart Association Class IV. He was diagnosed to have intact giant (11 cm × 11.5 cm × 12 cm) fusiform aneurysm of the distal aortic arch extending up to proximal descending thoracic aorta resulting in the displacement of trachea toward the right and left main bronchus inferiorly with underlying lung collapsed. The patient underwent distal arch replacement through midline sternotomy under deep hypothermic circulatory arrest with continuous selective antegrade cerebral perfusion using the right axillary artery and right femoral artery cannulation. The arch was replaced using 28-mm collagen impregnated, woven polyester graft. He remained stable postoperatively and was discharged on the 10th postoperative day.

Keywords: Aortic aneurysm, aortic arch replacement, deep hypothermic circulatory arrest, distal aortic arch, fusiform aneurysm, giant aortic aneurysm, saccular aneurysm, selective antegrade cerebral perfusion


How to cite this article:
Desai D, Kothari J, Brahmbhatt B. Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy. Indian J Vasc Endovasc Surg 2019;6:320-3

How to cite this URL:
Desai D, Kothari J, Brahmbhatt B. Management of intact giant fusiform aneurysm of distal aortic arch with impeding risk of rupture using midline sternotomy. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Jun 4];6:320-3. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/320/273589




  Introduction Top


Aneurysm of the distal aortic arch is relatively rare entity in the spectrum of cardiovascular diseases. Saccular aneurysms of the distal aortic arch or proximal descending aorta are reported in the literature. As reported in the literature, the saccular aneurysm of the distal aortic arch has very ominous natural history as compared to the typical fusiform aneurysm.[1] Very large fusiform aneurysm of the proximal descending aorta, involving the distal arch can present with contained rupture and have a very poor prognosis.[2] Such a giant fusiform aneurysm with impeding risk of rupture has not been reported in the literature. Aneurysm of the distal aortic arch is routinely repaired using left thoracotomy. However, with contained rupture, this approach appears rather unsafe.[3] Here, we are reporting an unusual case of giant intact fusiform aneurysm of the distal aortic arch with impeding risk of rupture managed successfully using midline sternotomy and deep hypothermic circulatory arrest with selective antegrade cerebral perfusion.


  Case Report Top


A 54-year-old gentleman presented with progressive dyspnea and chest pain in the New York Heart Association Class 4 over 2 years. On clinical examination, the patient had regular heart rate of 70 beats/min, with blood pressure of 130/90 mmHg. Cardiac auscultation was normal.

Electrocardiogram confirmed normal sinus rhythm. Echocardiography showed normal left ventricle size with ejection fraction of 55%. Chest radiography showed soft-tissue homogenous opacity in the left upper zone with widening of the superior mediastinum [Figure 1]. On further

workup, computed tomography of the thorax with contrast showed intact giant size (11 cm × 11.5 cm × 12 cm) fusiform aneurysm of the aortic arch distal to origin of the left subclavian artery extending up to proximal part of descending thoracic aorta resulting in the displacement of trachea toward the right and left main bronchus inferiorly with underlying lung collapse [Figure 2]. Conventional coronary angiogram was not performed due to unstable hemodynamics. He was advised for urgent surgical repair.
Figure 1: Preoperative chest radiograph showing homogeneous opacity in the left upper zone with widening of the superior mediastinum

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Figure 2: Intact giant fusiform aortic arch aneurysm distal to origin of the left subclavian artery with impeding risk of rupture resulting in the displacement of the trachea and left main bronchus

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Surgical technique

The decision to approach the lesion through midline sternotomy instead of left thoracotomy was taken to get better proximal control and improves the ease of repairing the aortic arch with adequate cerebral protection, as lesion was large enough to compress the surrounding structures such as the left subclavian artery superiorly and left pulmonary artery and left main bronchus inferiorly [Figure 3].
Figure 3: Intact giant fusiform aneurysm at the distal arch with relatively normal neck vessels and proximal arch

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Cardiopulmonary bypass was electively established using the right axillary artery, right common femoral artery, and bicaval cannulation. An 8-mm polytetrafluoroethylene graft was anastomosed to the right axillary artery in the end-to-side fashion for cannulation [Figure 4].
Figure 4: Right axillary artery side-graft cannulation technique

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Aneurysm was dissected free from the following surrounding structures – left subclavian artery and left pulmonary artery, left main bronchus, and underlying lung. In view of the difficulty in getting distal control, decision was taken to achieve deep hypothermic (18°C) circulatory arrest with selective antegrade cerebral perfusion with 20% of flow. All neck vessels were snared. After achieving total circulatory arrest, the fusiform aneurysm was opened longitudinally and organized thrombus was evacuated [Figure 5].
Figure 5: Intact giant aneurysm with massive clots

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A 28-mm collagen-impregnated woven polyester interposition graft was used to reconstruct the distal arch and proximal part of the descending aorta. Distal anastomosis was completed first in the end-to-end fashion, and lower body circulation reestablished using right femoral artery cannulation [Figure 6]a.
Figure 6: Interposition graft being anastomosed to the descending thoracic aorta. (a) Distal anastomosis (b) proximal anastomosis

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Similarly, the proximal end of the conduit anastomosed to the aortic arch in the extended end-to-end fashion to incorporate all three ostia of neck vessels [Figure 6]b. Intermittent cold sanguineous antegrade root cardioplegia was given for diastolic arrest to ensure adequate myocardial protection.

Postoperatively, the patient remained stable throughout his course in the hospital and was discharged on the 10th postoperative day [Figure 7]. On the first follow-up, computed tomography of the thorax with contrast showed patent interposition conduit without anastomotic leak [Figure 8].
Figure 7: Postoperative chest radiograph

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Figure 8: (a and b) Postoperative scan showing patent conduit in the interposition graft

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  Discussion Top


Saccular aneurysms have multiple etiologies, including infectious causes such as tuberculosis and syphilis, degenerative condition, progressive penetrating aortic ulcer, trauma or aortic surgery, and Takayasu arteritis.[4] Saccular aneurysms of aortic arch have higher risk of rupture than fusiform aneurysms. Fusiform aortic aneurysms are mainly due to connective tissue disorders. Open surgical repair of an aortic aneurysm involving the distal arch is challenging. Distal aortic arch aneurysms can be considered a subset of aneurysms of the descending thoracic aorta; therefore, left thoracotomy has been used as a standard approach. However, large fusiform aneurysm with contained rupture at distal arch can be approached safely through a midline sternotomy. In comparison to the saccular aneurysm, fusiform aneurysm of the distal arch is technically more demanding. The most important and tedious task is to get adequate control of densely adherent aneurysm through meticulous dissection. The decision to approach the lesion through midline sternotomy instead of left thoracotomy can be taken to get better proximal control and improves the ease of repairing the aortic arch with adequate cerebral protection, as fusiform aneurysm is large enough to compress the surrounding structures such as left subclavian artery superiorly and left pulmonary artery and left main bronchus inferiorly. Very minimal and gentle dissection around the arch and posterior to aneurysm can preserve important structures such as recurrent laryngeal nerve and phrenic nerve.

Recent techniques have produced very promising results, particularly in high-volume centers of excellence in aortic surgery. Various cerebral protection strategies can be used such as moderate hypothermia, deep hypothermia, antegrade cerebral perfusion, and retrograde cerebral perfusion.[5] Deep hypothermic total circulatory arrest with selective antegrade cerebral perfusion can be established easily using midline sternotomy approach.


  Conclusion Top


Giant fusiform distal aortic arch aneurysm with impeding risk of rupture remains very rare and lethal entity. Advanced cerebral and myocardial protection and a meticulous approach can reduce the rate of complications and mortality considerably. The operative approach we have described has not been priorly reported for intact giant fusiform aneurysm with impeding risk of rupture. We recommend this approach for similar large distal aortic arch aneurysms, as it exhibits low risk of perioperative complication.

Acknowledgment

The authors would like to acknowledge Ms. Himani Pandya for assistance.

Informed consent

Informed consent was obtained from the patient. This work was supported by U. N. Mehta Institute of Cardiology and Research Center itself and received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Taylor BV, Kalman PG. Saccular aortic aneurysms. Ann Vasc Surg 1999;13:555-9.  Back to cited text no. 1
    
2.
Yiu RS, Cheng SW. Natural history and risk factors for rupture of thoracic aortic arch aneurysms. J Vasc Surg 2016;63:1189-94.  Back to cited text no. 2
    
3.
Takayama H, Morota T, Motomura N, Ono M, Kotsuka Y, Takamoto S. Rupture of a small fusiform thoracic aortic aneurysm. Jpn J Thorac Cardiovasc Surg 2003;51:32-3.  Back to cited text no. 3
    
4.
Shang EK, Nathan DP, Boonn WW, Lys-Dobradin IA, Fairman RM, Woo EY, et al. Amodern experience with saccular aortic aneurysms. J Vasc Surg 2013;57:84-8.  Back to cited text no. 4
    
5.
Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S, et al. Prospective comparative study of brain protection in total aortic arch replacement: Deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001;72:72-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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