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Dissection of the Ascending Aorta: A Late Complication of Coronary Artery Bypass Grafting
1
8 CASE 3 4REPORT YAKUETAL
Ann ThoracSurg
DISSECTION OF ASCENDINGAORTAAFTERCABG
5. FujiwaraT, Yamane M, TakaharaI, et al. A case report of surgicallytreatedtuberculousfalse aneurysmof descending thoracicaorta. KyobuGeka 1977;30:91-5. 6. Quaini E, Donatelli F, Bonacina E, VitaJi E, Colombo T, PanzeriE. Mycotictuberculousaneurysmof the descending thoracicaorta.Tex HeartInst J 1985;12:257-60. 7. PatraP, GunnessT~ Feny D, et al. Tuberculousaneurysmof the descendingthoracicaorta.J Vase Surg 1987;6:408-11. 8. SandronD, Patra P, LelannP, BouillardJ, Pioche D. TuberCU1OUS pseudo-aneurysmof the descendingthora~icaorta. Eur RespirJ 1988;1:565-7.
Dissection of the Ascending Aorta: A Late Complication of Coronary Artery Bypass Grafting Hitoshi Yaku, MD, PhD, Gary G. Fermanis, FRACS, R. John Macauley,FRACP,and DavidA. Horton,FRACS Departmentof CardiothoracicSurge~, The St. George Hospital,Sydney,Australia
Acutedissectionof the ascendingaortaas a late complicationof coronaryarterybypassgraftinghas beenrarely reported.We reporta caseof a 61 year-old manin whom acutedissectionof theascendingaortadeveloped2 years after coronary artery bypass grafting. The ascending aortawas replacedwith a Dacrongraft,and an islandof the aorticwall,on whichpreviousproximalanastomoses had been placed, was implantedinto the Dacron graft successfully. (AnnThorac%% 1996;62:1834-5)
D
issection of the ascending aorta at the time of coronary artery bypass grafting is an uncommon but well-documented complication [1-3]. However, dissection of the ascei-ding aorta occurring late after corortaryartery bypass grafting is rare [3, 4]. We report a case of acute dissection of the ascending aorta occurring 2 years after coronary artery bypass grafting and successful repair.
A 61-year-old man had sudden onset of severe back pain radiating through to the buttock while teeing off at a golf course. He was transferred to The St. George Hospital. The patient had undergone coronary artery bypass grafting using three separate saphenous vein grafts 1 year 10 months before this episode. On admission, blood pressure was 130/70mm Hg. Chestroentgenography showed enlargement of the mediastinal shadow. Chest and abdominal computed tomography showed dissection of the thoracic aorta arising in the ascei’tding aorta and extend-
ing as far as the bifurcationof the commoniliacarteries. A transesophagealechocardiogramshowed an irdimal AcceptedforpublicationJune19, 1996. Addressreprirdrequeststo Dr l?ermanis,Departmentof Cardiothoracic Surgery,TheSt. GeorgeHospital,Kogarah,NSW2217,Au*.@.
01996 by The Society of ThoracicSurgeons Publishedby ElsevierScience Inc
1996;62:W&-5
flap arising just above the aortic valve. Neither aortic regurgitation nor pericardiaI effusion was detected. While the patient was under observation,ischemia of both legs developed,and urgentoperationfor the aortic dissectionwasundertaken(36hoursafterthe admission). Under general anesthesia,redo median sternotomy was performed.The ascendingaorta was dilated(about 6 cm in diameter).Cardiopulmonarybypasswas established between the right femoral artery and the right atrium.The patientwas cooled down to 19”C, and the circulationwas arrested.Whenthe aortawas transected, it became clear that the dissectionhad arisen from an area of the aorta betweenthe proximalanastomosesof the previoussaphenousveingrafts.Theintimalflapwas thin and friable,implyingthat the dissectionhad occurred recently.The native coronary orificeswere not invoked in the dissection.An island of the ascending aortic wall, on which the proximalanastomosesof the saphenousveingraftshad been place~ was excisedand the intimal flap was attached to the outer layer with gelatin-resorcin-formol(GRF) glue [5]. A cross-clamp was then appliedto the distalascendingaorta and the circulationwas recommenced. Gelatin-resorcin-formol gluewas injectedin the dissectedlayer of the proximal aortic stump. After about 5 minutes, a 30-mm Dacron prosthesis(GelseaLVascutek Scotland)was sewn into the proximalascendingaorta using4-OProlene(Ethicon, Somerville,NJ) continuoussutures.The circulationwas again arrested and the cross-clampwas removed. The distalaorticflapwasrepairedusingGRFglueinthe same fashionas the proximalaorta.The distalend of the graft was sewn to the ascending aorta using 4-O Prolene continuoussutures.A portion of the Dacron graft was removedand the islandof ascendingaorticwallwiththe proximalanastomoseswas artastomosedintothe Dacron graft using 4-OProlenecontinuoussutures (Fig 1). The circulationwas then recommence~ and the patientwas rewarmed.Weaningfromthe cardiopulmonarybypass was uneventfulusing a low-dose adrenalineinfusion. Transitoryrenal impairmentdevelopecLand the patient needed ventilato~ support for 5 days postoperatively. However,recoveryfrom those complicationswas satisfactory and the patient was discharged on the 12th postoperativeday. The patient remains well 1 year 6 monthsafter the operation. Comment In coronaryarterybypassgraftin~the ascendingaortais subjectedto manipulationssuch as cannulation,crossclampin~partialclampin~andproximalanastomosesof grafts.Each manipulationcould cause disruptionof the intimaof the ascendingaorta, resultingin pseudoaneurysm [2, 6] or acute dissectionof the ascendingaorta [1-3].Acutedissectionof the ascendingaortaat the same time as coronaryoperationor immediatelyafter operation and its management have been reported [1-3]. However,acute aortic dissectionoccurringlate after the initialcoronaryoperationis rarelyreported[3,4]. Nicholson [3] reported acute dissectionof the ascendingaoa’ta 0003-4975/96/$15.00 PII S0003-4975(%)00555-3
Ann Thorac Surg 1996;62:1835-7
CASE REPORT
MURPHY ETAL
CLOSTRIDIUM SEPTICUMMYCOTICANEURYSM
183.5
References 1. Litchford B, Okies E, Sugimura S, Starr A. Acute aortic dissection from cross-clamp injury. J Thorac Cardiovasc Surg 1976;72:709-13. 2. Boruchow IB, Iyengar R, Jude JR. Injury to ascending aorta by partial-occlusion clamp during aorta-coronary bypass. J Thorac Cardiovasc Surg 1977;73:303–5. 3. Nicholson WJ. Aortic root dissection complicating coronary bypass surge~. Am J Cardiol 1978;41:103-7. 4. Bopp P, Perrenoud JJ, Periat M. Dissection of ascending aorta. Rare complication of aortocoronary venous bypass surgery. Br Heart J 1981;46:571-3. 5. Guilmet D, Bachet J, Goudot B, et al. Use of biological glue in acute aortic dissection. Preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 1979;77:516–21. 6. Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138-43.
Fig 1. Repair of the ascending aorta. The previous coronay grafts were implanted to the Dacron graft as an island. occurring 8 months after coronary bypass grafting. How-
ever, it was assumed that dissection occurred at the time of operation, and details of the attempted surgical repair were not reported. Bopp and associates [4] reported ascending aortic dissection occurring 4 months after coronary bypass grafting, and this was treated conservatively. In our patient, acute dissection of the ascending aorta occurred 2 years after the initial coronary operation. We think that it is reasonable to assume that the dissection of the ascending aorta occurred in a weakened part of the intima of the aortic wall, associated with the proximal anastomoses. It has been reported that uncontrolled hypertension is a major risk factor in the causation of aortic dissection after open heart operations [2, 3]. This patient had a long history of hypertension and was receiving oral atenolol. Although his blood pressure on admission was in a normal range, he may well have been hypertensive beforehand and his blood pressure might have dropped into the normal range with the onset of the dissection. To repair the dissection of the ascending aorta, we adopted femoral arterial and right atrial cannuiations and circulatory arrest in the same way as in an ordinary case with acute dissection of the ascending aorta. We routinely use GRF glue to reconstruct the layers of the proximal and distal ends of the aorta. We find that graft anastomosis is easier and more secure using GRF glue than using Teflon felt strips. For management of the previous coronary grafts, the island of the ascending aortic wall including all proximal anastomoses was excised and repaired with GRF glue [5]. This island was implanted into the Dacron graft that had been used to replaced the ascending aorta. This proved to be a simple and secure technique in dealing with the intimal tear and previous coronary grafts, and there have been no untoward effects during follow-up. 01996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Mycotic Aneurysm of the Thoracic Aorta Caused by Clostridium septicum David P. Murphy, MD, David B. Glazier, MD, and Tyrone J. Krause, MD Division of Cardiac Surgexy, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
We describe a case of a 78-year-old man who presented with a mycotic aneurysm of the thoracic aorta caused by Clostridium septicum and underwent successful resection. There are only 3 cases of mycotic aneurysms caused by Clostridium septicum reported in the literature. Clostridium septicum infections have been shown to have a high association with gastrointestinal and hematologic malignancies. All patients with Clostridium septicum infections, therefore, require a search for gastrointestinal lesions, as they may represent a source of persistent bacteremia. This patient had no malignant lesions but did have multiple benign sigmoid polyps. (Ann Thorac Surg 1996;62:1835-7)
M
ycotic aneurysms have yielded various organisms. Gram-positive organisms, such as staphylococci, and gram-negative organisms, particularly SalmoneZZa, are among the most common. CZostridiumsepficum is an unusual cause of a mycotic aneurysm, but one with specific implications as the organism is usually present only in the setting of a gastrointestinal malignancy. This report describes a thoracic aneurysm caused by C septicum, which was successfully managed surgically. Accepted for publication June 20, 1996. Address reprint requests to Dr Krause, Division of Cardiac Surgesy, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ 08903.
0003-4975/96/$15.00 PII S0003-4975(96)00556-5
8 CASE 3 4REPORT YAKUETAL
Ann ThoracSurg
DISSECTION OF ASCENDINGAORTAAFTERCABG
5. FujiwaraT, Yamane M, TakaharaI, et al. A case report of surgicallytreatedtuberculousfalse aneurysmof descending thoracicaorta. KyobuGeka 1977;30:91-5. 6. Quaini E, Donatelli F, Bonacina E, VitaJi E, Colombo T, PanzeriE. Mycotictuberculousaneurysmof the descending thoracicaorta.Tex HeartInst J 1985;12:257-60. 7. PatraP, GunnessT~ Feny D, et al. Tuberculousaneurysmof the descendingthoracicaorta.J Vase Surg 1987;6:408-11. 8. SandronD, Patra P, LelannP, BouillardJ, Pioche D. TuberCU1OUS pseudo-aneurysmof the descendingthora~icaorta. Eur RespirJ 1988;1:565-7.
Dissection of the Ascending Aorta: A Late Complication of Coronary Artery Bypass Grafting Hitoshi Yaku, MD, PhD, Gary G. Fermanis, FRACS, R. John Macauley,FRACP,and DavidA. Horton,FRACS Departmentof CardiothoracicSurge~, The St. George Hospital,Sydney,Australia
Acutedissectionof the ascendingaortaas a late complicationof coronaryarterybypassgraftinghas beenrarely reported.We reporta caseof a 61 year-old manin whom acutedissectionof theascendingaortadeveloped2 years after coronary artery bypass grafting. The ascending aortawas replacedwith a Dacrongraft,and an islandof the aorticwall,on whichpreviousproximalanastomoses had been placed, was implantedinto the Dacron graft successfully. (AnnThorac%% 1996;62:1834-5)
D
issection of the ascending aorta at the time of coronary artery bypass grafting is an uncommon but well-documented complication [1-3]. However, dissection of the ascei-ding aorta occurring late after corortaryartery bypass grafting is rare [3, 4]. We report a case of acute dissection of the ascending aorta occurring 2 years after coronary artery bypass grafting and successful repair.
A 61-year-old man had sudden onset of severe back pain radiating through to the buttock while teeing off at a golf course. He was transferred to The St. George Hospital. The patient had undergone coronary artery bypass grafting using three separate saphenous vein grafts 1 year 10 months before this episode. On admission, blood pressure was 130/70mm Hg. Chestroentgenography showed enlargement of the mediastinal shadow. Chest and abdominal computed tomography showed dissection of the thoracic aorta arising in the ascei’tding aorta and extend-
ing as far as the bifurcationof the commoniliacarteries. A transesophagealechocardiogramshowed an irdimal AcceptedforpublicationJune19, 1996. Addressreprirdrequeststo Dr l?ermanis,Departmentof Cardiothoracic Surgery,TheSt. GeorgeHospital,Kogarah,NSW2217,Au*.@.
01996 by The Society of ThoracicSurgeons Publishedby ElsevierScience Inc
1996;62:W&-5
flap arising just above the aortic valve. Neither aortic regurgitation nor pericardiaI effusion was detected. While the patient was under observation,ischemia of both legs developed,and urgentoperationfor the aortic dissectionwasundertaken(36hoursafterthe admission). Under general anesthesia,redo median sternotomy was performed.The ascendingaorta was dilated(about 6 cm in diameter).Cardiopulmonarybypasswas established between the right femoral artery and the right atrium.The patientwas cooled down to 19”C, and the circulationwas arrested.Whenthe aortawas transected, it became clear that the dissectionhad arisen from an area of the aorta betweenthe proximalanastomosesof the previoussaphenousveingrafts.Theintimalflapwas thin and friable,implyingthat the dissectionhad occurred recently.The native coronary orificeswere not invoked in the dissection.An island of the ascending aortic wall, on which the proximalanastomosesof the saphenousveingraftshad been place~ was excisedand the intimal flap was attached to the outer layer with gelatin-resorcin-formol(GRF) glue [5]. A cross-clamp was then appliedto the distalascendingaorta and the circulationwas recommenced. Gelatin-resorcin-formol gluewas injectedin the dissectedlayer of the proximal aortic stump. After about 5 minutes, a 30-mm Dacron prosthesis(GelseaLVascutek Scotland)was sewn into the proximalascendingaorta using4-OProlene(Ethicon, Somerville,NJ) continuoussutures.The circulationwas again arrested and the cross-clampwas removed. The distalaorticflapwasrepairedusingGRFglueinthe same fashionas the proximalaorta.The distalend of the graft was sewn to the ascending aorta using 4-O Prolene continuoussutures.A portion of the Dacron graft was removedand the islandof ascendingaorticwallwiththe proximalanastomoseswas artastomosedintothe Dacron graft using 4-OProlenecontinuoussutures (Fig 1). The circulationwas then recommence~ and the patientwas rewarmed.Weaningfromthe cardiopulmonarybypass was uneventfulusing a low-dose adrenalineinfusion. Transitoryrenal impairmentdevelopecLand the patient needed ventilato~ support for 5 days postoperatively. However,recoveryfrom those complicationswas satisfactory and the patient was discharged on the 12th postoperativeday. The patient remains well 1 year 6 monthsafter the operation. Comment In coronaryarterybypassgraftin~the ascendingaortais subjectedto manipulationssuch as cannulation,crossclampin~partialclampin~andproximalanastomosesof grafts.Each manipulationcould cause disruptionof the intimaof the ascendingaorta, resultingin pseudoaneurysm [2, 6] or acute dissectionof the ascendingaorta [1-3].Acutedissectionof the ascendingaortaat the same time as coronaryoperationor immediatelyafter operation and its management have been reported [1-3]. However,acute aortic dissectionoccurringlate after the initialcoronaryoperationis rarelyreported[3,4]. Nicholson [3] reported acute dissectionof the ascendingaoa’ta 0003-4975/96/$15.00 PII S0003-4975(%)00555-3
Ann Thorac Surg 1996;62:1835-7
CASE REPORT
MURPHY ETAL
CLOSTRIDIUM SEPTICUMMYCOTICANEURYSM
183.5
References 1. Litchford B, Okies E, Sugimura S, Starr A. Acute aortic dissection from cross-clamp injury. J Thorac Cardiovasc Surg 1976;72:709-13. 2. Boruchow IB, Iyengar R, Jude JR. Injury to ascending aorta by partial-occlusion clamp during aorta-coronary bypass. J Thorac Cardiovasc Surg 1977;73:303–5. 3. Nicholson WJ. Aortic root dissection complicating coronary bypass surge~. Am J Cardiol 1978;41:103-7. 4. Bopp P, Perrenoud JJ, Periat M. Dissection of ascending aorta. Rare complication of aortocoronary venous bypass surgery. Br Heart J 1981;46:571-3. 5. Guilmet D, Bachet J, Goudot B, et al. Use of biological glue in acute aortic dissection. Preliminary clinical results with a new surgical technique. J Thorac Cardiovasc Surg 1979;77:516–21. 6. Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138-43.
Fig 1. Repair of the ascending aorta. The previous coronay grafts were implanted to the Dacron graft as an island. occurring 8 months after coronary bypass grafting. How-
ever, it was assumed that dissection occurred at the time of operation, and details of the attempted surgical repair were not reported. Bopp and associates [4] reported ascending aortic dissection occurring 4 months after coronary bypass grafting, and this was treated conservatively. In our patient, acute dissection of the ascending aorta occurred 2 years after the initial coronary operation. We think that it is reasonable to assume that the dissection of the ascending aorta occurred in a weakened part of the intima of the aortic wall, associated with the proximal anastomoses. It has been reported that uncontrolled hypertension is a major risk factor in the causation of aortic dissection after open heart operations [2, 3]. This patient had a long history of hypertension and was receiving oral atenolol. Although his blood pressure on admission was in a normal range, he may well have been hypertensive beforehand and his blood pressure might have dropped into the normal range with the onset of the dissection. To repair the dissection of the ascending aorta, we adopted femoral arterial and right atrial cannuiations and circulatory arrest in the same way as in an ordinary case with acute dissection of the ascending aorta. We routinely use GRF glue to reconstruct the layers of the proximal and distal ends of the aorta. We find that graft anastomosis is easier and more secure using GRF glue than using Teflon felt strips. For management of the previous coronary grafts, the island of the ascending aortic wall including all proximal anastomoses was excised and repaired with GRF glue [5]. This island was implanted into the Dacron graft that had been used to replaced the ascending aorta. This proved to be a simple and secure technique in dealing with the intimal tear and previous coronary grafts, and there have been no untoward effects during follow-up. 01996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Mycotic Aneurysm of the Thoracic Aorta Caused by Clostridium septicum David P. Murphy, MD, David B. Glazier, MD, and Tyrone J. Krause, MD Division of Cardiac Surgexy, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
We describe a case of a 78-year-old man who presented with a mycotic aneurysm of the thoracic aorta caused by Clostridium septicum and underwent successful resection. There are only 3 cases of mycotic aneurysms caused by Clostridium septicum reported in the literature. Clostridium septicum infections have been shown to have a high association with gastrointestinal and hematologic malignancies. All patients with Clostridium septicum infections, therefore, require a search for gastrointestinal lesions, as they may represent a source of persistent bacteremia. This patient had no malignant lesions but did have multiple benign sigmoid polyps. (Ann Thorac Surg 1996;62:1835-7)
M
ycotic aneurysms have yielded various organisms. Gram-positive organisms, such as staphylococci, and gram-negative organisms, particularly SalmoneZZa, are among the most common. CZostridiumsepficum is an unusual cause of a mycotic aneurysm, but one with specific implications as the organism is usually present only in the setting of a gastrointestinal malignancy. This report describes a thoracic aneurysm caused by C septicum, which was successfully managed surgically. Accepted for publication June 20, 1996. Address reprint requests to Dr Krause, Division of Cardiac Surgesy, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, New Brunswick, NJ 08903.
0003-4975/96/$15.00 PII S0003-4975(96)00556-5