The technique of balloon occlusion-assisted repair of a pseudoaneurysm originated from the side branch of an ascending aortic prosthetic graft via mini-thoracotomy

Abstract

A 69-year-old woman underwent aortic root reimplantation and graft replacement of the ascending aorta 12 years ago. A pseudoaneurysm (2.5 cm × 3 cm) arising from the side branch of the ascending aortic prosthetic graft was incidentally detected on contrast-enhanced computed tomography. After endovascular balloon occlusion of the side branch through the left subclavian artery, the side branch was exposed via right mini-thoracotomy in the third intercostal space. After circumferential dissection, the side branch was ligated uneventfully. The patient was discharged home on postoperative day 7 without any complications.

INTRODUCTION

Pseudoaneurysm arising from the prosthetic side branch has been reported as a rare late complication after aortic surgery [1, 2]. The standard approach for side branch pseudoaneurysm repair after ascending aortic surgery is median resternotomy. However, this approach increases the risk of pseudoaneurysm rupture during dissection to expose the side branch, which might lead to postoperative mortality and morbidity. Herein, we introduced the technique of balloon occlusion-assisted repair of a pseudoaneurysm originating from the side branch of an ascending aortic prosthetic graft via mini-thoracotomy.

CASE REPORT

The patient was a 69-year-old woman who had previously undergone 2 median sternotomies. She underwent aortic root reimplantation (Gelweave Valsalva 26 mm graft; Vascutek Ltd., Inchinnan, UK) and ascending aortic replacement using a single-branched Dacron graft (Hemashield 26–8 mm graft; Maquet, Rastatt, Germany) due to annuloaortic ectasia with an ascending aortic aneurysm 12 years ago. She then underwent aortic valve replacement using bioprosthesis for aortic valve insufficiency 7 years ago. Follow-up computed tomography incidentally revealed a pseudoaneurysm arising from the side branch of the ascending aorta prosthetic graft (25 mm × 30 mm) (Fig. 1A) without chest pain or other symptoms. The remnant side branch had a diameter of 9 mm and a length of 12 mm.

The pseudoaneurysm was located just beneath the sternum, and it was speculated that she had severe adhesions in the mediastinum caused by previous sternotomies. Therefore, we were concerned about massive bleeding during mediastinal dissection to expose the side branch.

A 5-cm transverse incision was made, and the third intercostal space was dissected to just beneath the rib. A 6F angled Parent Plus^® 60 guiding sheath (Medikit, Tokyo, Japan) was inserted into the ascending aorta and a Powerflex Pro balloon (10 mm diameter, 20-mm length; Cordis, CA, USA) was delivered into the side branch guided by a Core wire (Cook Medical, Bloomington, IN, USA). The balloon was inflated, and a complete occlusion was confirmed by angiography (Fig. 1B and C). The balloon occlusion allowed safe circumferential dissection of adhesion of the side branch without any bleeding. Immediately after the balloon was deflated and retrieved, the base of the side branch was tied down using 0 braided silk (Fig. 1D), and the stump was reinforced by a horizontal mattress and running sutures using 4–0 polypropylene. Skin incisions are shown in Fig. 1E. The patient was extubated in the operation room and was discharged to home on postoperative day 7 without any complications. Postoperative contrast-enhanced computed tomography demonstrated successful repair of the pseudoaneurysm (Fig. 1F).

COMMENT

Median resternotomy is the standard approach for ascending aortic pseudoaneurysm repair, but this carries the risks of pseudoaneurysm rupture during dissection. An alternative to median sternotomy for side branch pseudoaneurysm repair is endovascular treatment. According to previous reports, one such option is thoracic endovascular aortic repair (TEVAR) to cover the root of the side branch [1, 2]. However, in the current case, the prosthetic ascending aortic graft was too short and bent to perform TEVAR, and the remnant side branch was also too short and bent to perform embolization using a vascular plug or coil. Therefore, we performed balloon occlusion-assisted repair via mini-thoracotomy.

As in previous reports, the cause of pseudoaneurysm formation in our case has not been elucidated including infection. As there has been a report of pseudoaneurysm formation after double-ligation using braided silk [1], it may have occurred due to age-related deterioration of the silk. To avoid the recurrence of side branch pseudoaneurysm, it might be best to add polypropylene sutures or other sutures as well as perform ligation with braided silk.

The balloon occlusion-assisted repair technique may be useful for a pseudoaneurysm originating from the side branch of a prosthetic graft when TEVAR and catheter embolization are not anatomically suitable.

SUPPLEMENTARY MATERIAL

Supplementary material is available at EJCTS online.

ACKNOWLEDGEMENT

The authors thank Kelly Zammit, BVSc, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

CONSENT

Informed consent was obtained from the patient for all procedures and for the publication of this case report.

Conflict of interest: none declared.

Data Availability

The authors declare that all data in this article are available within the article.

Reviewer information

European Journal of Cardio-Thoracic Surgery thanks Tim Berger, Clarence Pienteu Pingpoh and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.

REFERENCES