- Email: [email protected]
Aortic pseudoaneurysm complicating sternal wound infection following CABG
doi:10.1016/S0967-2109(03)00015-2
Cardiovascular Surgery, Vol. 11, No. 3, pp. 243–245, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Science Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
CASE REPORT Aortic pseudoaneurysm complicating sternal wound infection following CABG Mohan P. Devbhandari∗, Sendhil K. Balasubramanian†, Ciro Campanella† and Edward T. Brackenbury† ∗
Department of Cardiothoracic Surgery, Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, FY3 8NR, UK and †Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK Pseudoaneurysm of the ascending aorta following coronary artery bypass grafting is a rare complication. In this report we present two such cases. We were successful in repairing the false aneurysm and sternal dehiscence in one case. The clinical features, diagnosis and surgical management are discussed. 2003 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved. Keywords: aorta, pseudoaneurysm, CABG, infection
Pseudoaneurysm of the ascending aorta is a challenging surgical problem, which is made even more difficult in the presence of overlying sternal wound infection. The surgical management affords a formidable challenge, which has to include repair of false aneurysm with debridement of sternal wound and soft tissue and skin cover of the wound. The surgical outcome is variable as highlighted by two cases presented here.
Case reports Case 1 A 43-year-old male underwent five coronary artery bypass graft with bilateral internal mammary arteries, radial artery and two vein grafts. His significant co morbidities were hypertension and noninsulin dependent diabetes mellitus. Cardiopulmonary bypass was achieved by cannulating ascending aorta and right atrium. After de-cannulation the cannulation site was closed with double purse string sutures of 2/0 ethibond (Ethicon Ltd.,
Correspondence to: M.P. Devbhandara FCRS. Tel.: +44-1253300000 ext 4056; fax: +44-1253-303669; e-mail: [email protected]
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
Edinburgh, UK) and over-sewn with 4/0 prolene (Ethicon Ltd., Edinburgh). He made a satisfactory recovery from operation initially but later developed a chest wound infection with staphylococcus aureus. He was readmitted and treated with appropriate antibiotic and local dressing along with application of a negative suction device. Wound started to improve. One evening he was noted to have profuse dark coloured seropurulent discharge from the wound (12 weeks from date of operation). Next day he developed a pulsatile and expansile mass over the sternal wound leaking arterialised blood. A clinical diagnosis of rupturing pseudoaneurysm was made and patient was immediately taken to the theatre. Cardiopulmonary bypass was established by cannulating the left common femoral artery and vein and the patient cooled. A small left anterior thoracotomy was made to insert an LV apical vent. At 18°C the circulation was stopped, blood drained out and the sternum dissected. A large pseudoaneurysm cavity was seen at the bottom of which was a 1.5 cm hole arising from aortic cannulation site. An autologous pericardial patch was used to seal off the defect in the aortic wall feeding the false aneurysm. Bypass was re-established and the patient rewarmed. The abdomen was opened and omentum was mobilised to fill the space left by pseudoaneurysm cavity. The sternum was debrided and infected bone was nibbled 243
Aortic pseudoaneurysm following CABG: Mohan P. Devbhandari et al.
away. The chest was left open overnight and was closed next day by mobilising pectoral myocutaneous flaps. Postoperatively the patient developed a collection at the top part of the wound, which was evacuated and the wound healed and he was discharged home. He was reviewed in the clinic after three months when he was found to be completely free of angina and all the wounds were well healed. Case 2 A 74-year-old male underwent quadruple coronary artery bypass graft with bilateral internal mammary arteries and two vein grafts for severe triple vessel coronary artery disease. His significant past medical history included hypertension, diet controlled diabetes, prostatic hypertrophy and transient ischemic attacks. The arterial cannulation site in the ascending aorta was closed with two 2/0 ethibond purse strings and over-sewn with 4/0 prolene. His immediate postoperative recovery was complicated by chest infection and atrial fibrillation and was discharged on the 12th postoperative day. He was readmitted a month later with methicillin resistant staphylococcus aureus (MRSA) infection of his sternal wound. He was treated with intravenous vancomycin and local dressing and application of a negative suction device to sternal wound. His wound healed and he was discharged home. He presented five months later with a pulsating expansile mass in the upper half of sternum. Chest x-ray showed widened mediastinum with small right-sided pleural effusion and computerized tomography scan (Figure 1) revealed a pseudoaneurysm of the ascending aorta. He was taken to theatre for emergency repair of the infected pseudoaneurysm of the ascending aorta. Cardiopulmonary bypass was established by cannulating the right femoral vein and common femoral
artery and the patient was cooled. A small left anterior thoracotomy was made to insert a left ventricular apical vent. When the temperature approached 25°C re-sternotomy was commenced which unfortunately resulted in rupture of false aneurysm which appeared to arise from the aortic cannulation site. Circulation was arrested and an attempt was made to repair the aorta. The pulsating mass was eroding through the sternum and discharged haemorrhagic and purulent material. There was very dense adhesion between the aorta and sternum. Because of extensive infection of the aortic wall and surrounding structures any attempt at repair was fruitless. The friable tissue did not hold stitches and the patient died due to exsanguination.
Comments Pseudoaneurysm following a coronary artery bypass operation is a rare but serious complication which can present in a variety of ways [1–3] from anastomotic sites, cannulation sites, suture lines and needle punctures sites at variable intervals from operation [4].The sternal wound infection predisposes to formation of false aneurysm. It is possible that application of negative wound suction could perhaps have contributed to enlargement of false aneurysm once it started to form. It may also cause early superficial closure concealing the underlying pathology. Profuse bloody discharge from a sternal wound with no apparent abscess cavity should raise the suspicion of a leak from a false aneurysm formation. The finding of an enlarging pulsatile swelling warrants emergent surgical repair. CT scan with contrast enhancement can clearly show the aneurysm. Femorofemoral bypass and deep hypothermic circulatory arrest is the technique of choice. Left ventricular venting can be done through a left anterior thoracotomy. Alternatively heartport access has been used which can be used to vent the LV as well as delivering antegrade cardioplegia [5]. All infected tissues and wall of false aneurysm has to be excised. Defect can be repaired with a variety of synthetic and biological patches. Omental transfer is a very useful procedure to fill the dead space and to achieve cover as well as vascularity. Additional plastic surgical technique may be required to achieve skin cover. It still remains a formidable task with a high operative risk.
References
Figure 1 CT scan of the patient showing the pseudoaneurysm filled with contrast lying between the aorta and the sternum.
244
1. Morissette, M., Lemire, J., Poirier, N. et al. False aneurysm of the ascending aorta presenting as an acute myocardial infarction: a late complication of aortocoronary bypass. Chest, 1981, 79(5), 591–592. 2. Grishkin, B. A. and Helsel, R. A. Aortic pseudoaneurysm after ligation of aneurysmal saphenous vein graft. Ann Thorac Surg, 2000, 69(1), 271–273. 3. Rampoldi, V., Trimarchi, S., Tolva, V. et al. Proximal pseudoane-
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
Aortic pseudoaneurysm following CABG: Mohan P. Devbhandari et al. urysm of ascending-abdominal aortic bypass. Eur J Cardiothorac Surg, 2001, 19(4), 531–533. 4. Linz, P., Wallace, R. and Baker, W. Long-term follow-up and resection of a postoperative false aortic aneurysm. Ann Thorac Surg, 1993, 55, 758–759. 5. D’Attellis, N., Diemont, F. F., Julia, P. L. et al. Management of
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
pseudoaneurysm of the ascending aorta performed under circulatory arrest by port-access. Ann Thorac Surg, 2001, 71(3), 1010– 1011.
245
Cardiovascular Surgery, Vol. 11, No. 3, pp. 243–245, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Science Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
CASE REPORT Aortic pseudoaneurysm complicating sternal wound infection following CABG Mohan P. Devbhandari∗, Sendhil K. Balasubramanian†, Ciro Campanella† and Edward T. Brackenbury† ∗
Department of Cardiothoracic Surgery, Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, FY3 8NR, UK and †Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK Pseudoaneurysm of the ascending aorta following coronary artery bypass grafting is a rare complication. In this report we present two such cases. We were successful in repairing the false aneurysm and sternal dehiscence in one case. The clinical features, diagnosis and surgical management are discussed. 2003 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved. Keywords: aorta, pseudoaneurysm, CABG, infection
Pseudoaneurysm of the ascending aorta is a challenging surgical problem, which is made even more difficult in the presence of overlying sternal wound infection. The surgical management affords a formidable challenge, which has to include repair of false aneurysm with debridement of sternal wound and soft tissue and skin cover of the wound. The surgical outcome is variable as highlighted by two cases presented here.
Case reports Case 1 A 43-year-old male underwent five coronary artery bypass graft with bilateral internal mammary arteries, radial artery and two vein grafts. His significant co morbidities were hypertension and noninsulin dependent diabetes mellitus. Cardiopulmonary bypass was achieved by cannulating ascending aorta and right atrium. After de-cannulation the cannulation site was closed with double purse string sutures of 2/0 ethibond (Ethicon Ltd.,
Correspondence to: M.P. Devbhandara FCRS. Tel.: +44-1253300000 ext 4056; fax: +44-1253-303669; e-mail: [email protected]
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
Edinburgh, UK) and over-sewn with 4/0 prolene (Ethicon Ltd., Edinburgh). He made a satisfactory recovery from operation initially but later developed a chest wound infection with staphylococcus aureus. He was readmitted and treated with appropriate antibiotic and local dressing along with application of a negative suction device. Wound started to improve. One evening he was noted to have profuse dark coloured seropurulent discharge from the wound (12 weeks from date of operation). Next day he developed a pulsatile and expansile mass over the sternal wound leaking arterialised blood. A clinical diagnosis of rupturing pseudoaneurysm was made and patient was immediately taken to the theatre. Cardiopulmonary bypass was established by cannulating the left common femoral artery and vein and the patient cooled. A small left anterior thoracotomy was made to insert an LV apical vent. At 18°C the circulation was stopped, blood drained out and the sternum dissected. A large pseudoaneurysm cavity was seen at the bottom of which was a 1.5 cm hole arising from aortic cannulation site. An autologous pericardial patch was used to seal off the defect in the aortic wall feeding the false aneurysm. Bypass was re-established and the patient rewarmed. The abdomen was opened and omentum was mobilised to fill the space left by pseudoaneurysm cavity. The sternum was debrided and infected bone was nibbled 243
Aortic pseudoaneurysm following CABG: Mohan P. Devbhandari et al.
away. The chest was left open overnight and was closed next day by mobilising pectoral myocutaneous flaps. Postoperatively the patient developed a collection at the top part of the wound, which was evacuated and the wound healed and he was discharged home. He was reviewed in the clinic after three months when he was found to be completely free of angina and all the wounds were well healed. Case 2 A 74-year-old male underwent quadruple coronary artery bypass graft with bilateral internal mammary arteries and two vein grafts for severe triple vessel coronary artery disease. His significant past medical history included hypertension, diet controlled diabetes, prostatic hypertrophy and transient ischemic attacks. The arterial cannulation site in the ascending aorta was closed with two 2/0 ethibond purse strings and over-sewn with 4/0 prolene. His immediate postoperative recovery was complicated by chest infection and atrial fibrillation and was discharged on the 12th postoperative day. He was readmitted a month later with methicillin resistant staphylococcus aureus (MRSA) infection of his sternal wound. He was treated with intravenous vancomycin and local dressing and application of a negative suction device to sternal wound. His wound healed and he was discharged home. He presented five months later with a pulsating expansile mass in the upper half of sternum. Chest x-ray showed widened mediastinum with small right-sided pleural effusion and computerized tomography scan (Figure 1) revealed a pseudoaneurysm of the ascending aorta. He was taken to theatre for emergency repair of the infected pseudoaneurysm of the ascending aorta. Cardiopulmonary bypass was established by cannulating the right femoral vein and common femoral
artery and the patient was cooled. A small left anterior thoracotomy was made to insert a left ventricular apical vent. When the temperature approached 25°C re-sternotomy was commenced which unfortunately resulted in rupture of false aneurysm which appeared to arise from the aortic cannulation site. Circulation was arrested and an attempt was made to repair the aorta. The pulsating mass was eroding through the sternum and discharged haemorrhagic and purulent material. There was very dense adhesion between the aorta and sternum. Because of extensive infection of the aortic wall and surrounding structures any attempt at repair was fruitless. The friable tissue did not hold stitches and the patient died due to exsanguination.
Comments Pseudoaneurysm following a coronary artery bypass operation is a rare but serious complication which can present in a variety of ways [1–3] from anastomotic sites, cannulation sites, suture lines and needle punctures sites at variable intervals from operation [4].The sternal wound infection predisposes to formation of false aneurysm. It is possible that application of negative wound suction could perhaps have contributed to enlargement of false aneurysm once it started to form. It may also cause early superficial closure concealing the underlying pathology. Profuse bloody discharge from a sternal wound with no apparent abscess cavity should raise the suspicion of a leak from a false aneurysm formation. The finding of an enlarging pulsatile swelling warrants emergent surgical repair. CT scan with contrast enhancement can clearly show the aneurysm. Femorofemoral bypass and deep hypothermic circulatory arrest is the technique of choice. Left ventricular venting can be done through a left anterior thoracotomy. Alternatively heartport access has been used which can be used to vent the LV as well as delivering antegrade cardioplegia [5]. All infected tissues and wall of false aneurysm has to be excised. Defect can be repaired with a variety of synthetic and biological patches. Omental transfer is a very useful procedure to fill the dead space and to achieve cover as well as vascularity. Additional plastic surgical technique may be required to achieve skin cover. It still remains a formidable task with a high operative risk.
References
Figure 1 CT scan of the patient showing the pseudoaneurysm filled with contrast lying between the aorta and the sternum.
244
1. Morissette, M., Lemire, J., Poirier, N. et al. False aneurysm of the ascending aorta presenting as an acute myocardial infarction: a late complication of aortocoronary bypass. Chest, 1981, 79(5), 591–592. 2. Grishkin, B. A. and Helsel, R. A. Aortic pseudoaneurysm after ligation of aneurysmal saphenous vein graft. Ann Thorac Surg, 2000, 69(1), 271–273. 3. Rampoldi, V., Trimarchi, S., Tolva, V. et al. Proximal pseudoane-
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
Aortic pseudoaneurysm following CABG: Mohan P. Devbhandari et al. urysm of ascending-abdominal aortic bypass. Eur J Cardiothorac Surg, 2001, 19(4), 531–533. 4. Linz, P., Wallace, R. and Baker, W. Long-term follow-up and resection of a postoperative false aortic aneurysm. Ann Thorac Surg, 1993, 55, 758–759. 5. D’Attellis, N., Diemont, F. F., Julia, P. L. et al. Management of
CARDIOVASCULAR SURGERY
JUNE 2003 VOL 11 NO 3
pseudoaneurysm of the ascending aorta performed under circulatory arrest by port-access. Ann Thorac Surg, 2001, 71(3), 1010– 1011.
245