Invited Commentary

Abstract

The treatment pendulum is swinging in many areas of aortic surgery away from open repair toward a less invasive approach using endovascular technologies. However, the current study by Dr Malvindi and colleagues [1Malvindi P.G. van Putte B.P. Heijmen R.H. Schepens M.A.A.M. Morshuis W.J. Reoperations for aortic false aneurysms after cardiac surgery.Ann Thorac Surg. 2010; 90: 1437-1443Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar] demonstrates with regards to the complex subject of reoperation for aortic pseudoaneurysms after prior cardiac operations that open surgical repair remains the most prudent and successful approach. Several factors lead to the development of aortic pseudoaneurysms in patients with a history of cardiac operations; however, it appears that it is becoming a more frequent diagnosis. This study describes 43 cases of aortic pseudoaneurysm in patients with prior cardiac operations over a 14-year period. Many of these patients were asymptomatic at the time of diagnosis, which demonstrates the clinical need for regular computed tomography screening in any patient with a previous aortic operation. In addition, with more high-resolution computed tomography scans being performed, various other focal aortic defects are being identified that may require the same surgical treatment principles as described in their article. One of the most critical aspects of this type of surgical repair is the management of cardiopulmonary bypass cannulation to most safely reenter the chest. Before the chest was opened, 14 patients in this series had initiation of cardiopulmonary bypass and 5 patients in this series needed hypothermic circulatory arrest due to adherence of the aortic pseudoaneurysm to the posterior aspect of the sternum. The authors use the criteria of less than 2 cm of distance between the sternum and the aortic aneurysm on preoperative imaging on when to pursue this approach. Certainly, the excellent outcomes described in this article are directly related to the success of this algorithm. The final important surgical principle that their article highlights is the need for extensive debridement of the pseudoaneurysm and surrounding aortic tissue. One-third of the pseudoaneurysms were related to infection, and 70% of the patient cohort received an aortic graft replacement. Without aggressive repair, these lesions may recur or achieve an inadequate resection. As the authors correctly discuss, endovascular techniques, including hybrid repair, have been described for the treatment of this problem. However, with the excellent surgical outcomes listed in this article, it is difficult to deny patients an open surgical resection. Some patients at high surgical risk may benefit from the less invasive approach, but all of the patients in this study were undergoing redo procedures and had many medical comorbidities. In addition, many of the lesions described in this report were in an unfavorable location for an endovascular approach. Until endovascular technologies advance significantly, an open surgical repair using the principles and techniques listed in this article for aortic pseudoaneurysms in patients with prior cardiac operations should be considered the definitive approach. Reoperations for Aortic False Aneurysms After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 90Issue 5PreviewAortic false aneurysm is a rare complication after cardiac surgery. Aortic dissection, infection, arterial wall degeneration, and poor surgical technique are recognized as risk factors for the occurrence of postsurgical false aneurysm. Despite some recent reports about percutaneous false aneurysm exclusion, a complex surgical reoperation is needed in most of the cases. Full-Text PDF