Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 247-249

Off-pump open repair of false aneurysm of aortic isthmus: This technique is still relevant


1 Department of Cardiovascular and Thoracic Surgery, University Hospital of Tingandogo, Ouagadougou, Burkina Faso; Department of Cardiovascular and Thoracic Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
2 Department of Orthopedics, Zaozhuang Municipal Hospital, Zaozhuang, Shandong Province, China
3 Department of Cardiovascular and Thoracic Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France

Date of Submission29-Jun-2020
Date of Decision26-Jul-2020
Date of Acceptance01-Aug-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Adama Sawadogo
Department of Cardiovascular and Thoracic Surgery, University Hospital of Tingandogo, Ouagadougou, Burkina Faso; Department of Cardiovascular and Thoracic Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_90_20

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  Abstract 


Pseudoaneurysm is a rare long-term complication following coarctation of aorta repair. Thoracic endovascular aortic repair is the most common approach. However, under some circumstances, this cannot be performed. Therefore, the traditional open approach is indicated. Although the potential ischemia of spinal cord is related to this approach, it remains an efficient alternative. The authors report a case of late pseudoaneurysm of the distal aortic arch following coarctation of aorta repair in a 26-year-old male that has been successfully repaired by left thoracotomy.

Keywords: Coarctation of aorta, false aneurysm, open repair, thoracic aorta


How to cite this article:
Sawadogo A, Wang H, D'Ostrevy N, Camilleri L. Off-pump open repair of false aneurysm of aortic isthmus: This technique is still relevant. Indian J Vasc Endovasc Surg 2021;8:247-9

How to cite this URL:
Sawadogo A, Wang H, D'Ostrevy N, Camilleri L. Off-pump open repair of false aneurysm of aortic isthmus: This technique is still relevant. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:247-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/247/320629




  Introduction Top


The long-term follow-up of patients who underwent coarctation of aorta repair demonstrated late problems such as recoarctation, and late pseudoaneurysm formation.[1] The incidence of aneurysms after surgical treatment of aortic coarctation has been reported between 11% and 24%.[2],[3] Traditional treatments of these pseudoaneurysms consist of open approach. With advancement in interventional techniques, complex aortic pathologies are becoming increasingly feasible to thoracic endovascular aortic repair (TEVAR). However, these procedures can be very challenging and carry potential pitfalls if adequate preoperative planning is not performed.[1] In these situations, open repair appears to remain an effective and efficient approach. The authors report a case of pseudoaneurysm of the distal aortic arch following coarctation of aorta repair that has been successfully treated by open approach.


  Case Report Top


The patient was a 26-year-old male who grown up with congenital heart defect. At the age of 6 months, he underwent repair of coarctation of aorta (end-to-end anastomosis) by left postero-lateral thoracotomy through the third intercostal space. Nine months later, he underwent ventricular septal defect repair by sternotomy. Recently, the patient consulted his cardiologist for dyspnea New York Heart Association class 2. On clinical examination, he appeared thin with a body mass index of 19. There was no other abnormal clinical finding. Transthoracic echocardiogram was normal. Aortic angio computed tomography (CT) scan [Figure 1] showed a large aneurysm of 42 mm at the isthmus, while the rest of the aorta is small (21 mm × 24 mm). The same finding could be seen on magnetic resonance imaging (MRI). Due to symptoms and risk of complications, a decision to repair by open approach was made. The patient was positioned on right lateral decubitus position. Before starting incision, a cardiopulmonary bypass machine was prepared and the perfusionist stayed in the operating theater during the procedure's time [Figure 2]. A postero-lateral thoracotomy through the third left intercostal space was performed. The scapula was lifted with a retractor to ease the access into the pleural space. The distal arch and proximal descending aorta were dissected and controlled. The aneurysm was located at the distal arch just contiguous to the suture line of the coarctation repair and was engaging the ostium of the left subclavian artery (SCA) [Figure 3]. No intercostal branch was injured. Then, double clamping of the aorta was done before and after the aneurysm; a third clamping was done above the origin of the left SCA. The aneurysm was resected, revealing a particularly thin wall of the proximal aortic edge [Figure 4]. A repair by end-to-end anastomosis with a 20-mm graft was performed by running the suture proximally and distally with Surgilène® 4/0 [Figure 5]. Aortic clamping lasted 25 min. Afterward, the left SCA was re-implanted in the graft by lateral clamping with an 8-mm tube. We did not use cerebrospinal fluid drainage during this procedure because our anesthetists do not use this protocol. However, we used near-infrared spectroscopy to monitor the brain activity. No arrhythmia happened during the procedure and thereafter, the patient had 24-h uneventful stay in the cardiac intensive care unit. In particular, there was neither lower limb motor deficit nor organ hypoperfusion syndrome. The patient discharged from the hospital on day 9 postoperatively.
Figure 1: Angio computed tomography of the thoracic aorta

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Figure 2: Cardiopulmonary bypass machine prepared to be used, if necessary

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Figure 3: Surgical view of the false aneurysm

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Figure 4: False aneurysm flattened showing thin proximal edge and normal distal one

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Figure 5: Twenty-millimeter aortic graft and 8-mm left subclavian artery tube

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  Discussion Top


Nowadays, TEVAR is the most common approach to treat isthmic and descending thoracic aortic aneurysms. In our case, due to the small size of the adjacent aorta and the previous history of multiple congenital heart diseases, we preferred the open approach. This was eased by the limited length of the aneurysm and the absence of intercostal branch within the zone of dissection. Over half a century after the first successful surgery for aneurysms of the descending thoracic aorta (DTA) by Etheredge (in 1955) and De Bakey (in 1956), ischemic spinal cord injury remains the most devastating complication after repair by any modality.[4],[5] Clinical studies have demonstrated that the duration of aortic cross-clamping is a major determinant of postoperative paraplegia. The rate of paraplegia increases from 0% when the cross-clamp time is <15 min, to 25%–100% when the time exceeds 60 min.[6],[7] We did not find it necessary to use cardiopulmonary bypass or shunts as we were able to achieve aortic replacement relatively fast. It should be remembered that the onset of neurologic signs may be early or delayed during the postoperative course, and deterioration is more frequently progressive than abrupt. The suspicion of such a causal mechanism should prompt emergency MRI or CT to obtain a diagnosis as soon as possible.[8]


  Conclusion Top


False aneurysm is a rare and late complication following coarctation of aorta repair. In this era of endovascular therapies and under some circumstances, open repair is still an efficient approach to cure the DTA aneurysms.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parsa P, Eidt J, Ri-Os A, Gable D, Vasquez J Jr. Case report: An innovative endovascular technique for repair of descending thoracic aortic aneurysm following an open coarctation repair. Ann Vasc Surg 2018;46:205.e1.  Back to cited text no. 1
    
2.
Cramer JW, Ginde S, Bartz PJ, Tweddell JS, Litwin SB, Earing MG. Aortic aneurysms remain a significant source of morbidity and mortality after use of Dacron(®) patch aortoplasty to repair coarctation of the aorta: Results from a single center. Pediatr Cardiol 2013;34:296-301.  Back to cited text no. 2
    
3.
von Kodolitsch Y, Aydin MA, Koschyk DH, Loose R, Schalwat I, Karck M, et al. Predictors of aneurysmal formation after surgical correction of aortic coarctation. J Am Coll Cardiol 2002;39:617-24.  Back to cited text no. 3
    
4.
Conrad MF, Crawford RS, Davison JK, Cambria RP. Thoracoabdominal aneurysm repair: A 20-year perspective. Ann Thorac Surg 2007;83:S856-61.  Back to cited text no. 4
    
5.
Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: A position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg 2015;47:943-57.  Back to cited text no. 5
    
6.
Livesay JJ, Cooley DA, Ventemiglia RA, Montero CG, Warrian RK, Brown DM, et al. Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg 1985;39:37-46.  Back to cited text no. 6
    
7.
Katz NM, Blackstone EH, Kirklin JW, Karp RB. Incremental risk factors for spinal cord injury following operation for acute traumatic aortic transection. J Thorac Cardiovasc Surg 1981;81:669-74.  Back to cited text no. 7
    
8.
Biglioli P, Roberto M, Cannata A, Parolari A, Spirito R. Paraplegia after iatrogenic extrinsic spinal cord compression after descending thoracic aorta repair: case report and literature review. J Thorac Cardiovasc Surg 2002;124:407-10.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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