Resection Of Pseudoaneurysm Research Articles

Respiratory Distress after Surgery of RVOT Pathologies: A Word of Caution on Pseudoaneurysm Development

Pseudoaneurysm of the right ventricle outflow tract (RVOT) is a rare complication in pediatric cardiac surgery. We report a patient who developed a right ventricular pseudoaneurysm 8 months after RVOT enlargement using a pericardial patch for infundibular pulmonary stenosis. Our patient was born with severe pulmonary valvular stenosis and treated with percutaneous balloon valvotomy in the neonatal period. Six months later, she developed infundibular pulmonary stenosis, which required surgical resection of right ventricle infundibular trabeculations and bovine pericardial patch enlargement. The postoperative period was normal. She was readmitted to hospital 5 months later complaining of wheezing, coughing and shortness of breath. Echocardiography showed a huge aneurysmal dilatation of the outflow patch in connection with the right ventricular cavity. The patient underwent resection of the pseudoaneurysm and former patch, followed by interposition of a bovine jugular vein conduit between the RVOT and pulmonary bifurcation. The early postoperative period was uncomplicated. On echocardiography, no significant residual gradient was measured through the conduit and there was no insufficiency of the valve. RVOT reconstruction with patch enlargement, homograft or conduit implantation can be the origin of pseudoaneurysms. Although their incidence is rare, they are often asymptomatic before becoming quite large and causing compression symptoms as in our patient with respiratory complaints due to airway compression. It is important to follow up these patients closely, especially in the first year after surgery since most aneurysms develop within 6 months of surgery.

Ungewöhnliche Ursache einer Staphylococcus-aureus-Septikämie bei einem 79-jährigen Patienten

High grade fever in the context of Staphylococcus aureus bacteremia led to hospital admission of a 79 year old male patient. A covered perforation of the ascending aorta resulted in the formation of a pseudoaneurysm which was complicated by superinfection caused by hematogenic spread of Staphylococcus aureus. The infected pseudoaneurysm found per continuitatem contact to the pericardium and resulted in bacterial pericarditis. Antibiotic pretreatment was followed by operation with a complex procedure including resection of pseudoaneurysm and suture closure of the perforation site.

PP-150 PERCUTANEOUS EXTRACTION OF CARDIAC PACEMAKER AND IMPLANTABLE CARDIOVERTER DEFIBRILLATOR LEADS WITH A NEW TOOL; A SINGLE CENTER EXPERIENCE

Methods: A 70 year old man who presented with a history of class II heart failure was found to have a left ventricular pseudoaneurysm. Cardiac magnetic resonance angiography and echocardiography showed a large pseudoaneurysm with a neck of approximately 24 mm, and a high velocity bi-directional jet between the posterolateral wall of the left ventricle (LV) and a vast sump. Hand contrast angiography together with conventional angiography confirmed a communication between the LV cavity and a large false cavity. A trans-septal catheterization was deemed suitable as the delivery catheter length would preclude a femoral arterial approach. Results: A 24 mm Amplatzer sizing balloon was advanced into the pseudoaneurysm cavity which sized the orifice at 22 mm. A 10 French Amplatzer sheath was passed through the defect and a 26 mm Amplatzer septal occluder was deployed across the defect (1F). We noticed a collapse in the center of the discus deployed on the ventricular site suggesting that the design of the device may not be strong enough to withstand the pressure difference. Upon release of the delivery system, the device was dislocated. We attempted to retrieve the device with a snare catheter but we were unsuccessful. Afterwards the patient was given to surgery for device removal, and pseudoaneurysm resection. Unfortunately he died during early post-operative period. Conclusions: The novel and important aspects of our intervention is that a femoral vein approach with trans-septal puncture is safe and effective for percutaneous closure of a left ventricular pseudoaneurysm. We recommend a gentile Minnesota maneuver to be employed just to make sure releasing the delivery system is safe. A different Amplatzer device with a more robust design on one discus, which would be deployed on the ventricular site could be more appropriate for closure of a larger left ventricular pseudoaneurysm.

PP-151 THE SAFETY AND EFFICACY OF THE ANGIO-SEAL CLOSURE DEVICE IN DIAGNOSTIC AND INTERVENTIONAL CARDIOLOGY SETTING: PRELIMINARY RESULTS OF SINGLE-CENTER EXPERIENCE WITH 551 CLOSURES

Methods: A 70 year old man who presented with a history of class II heart failure was found to have a left ventricular pseudoaneurysm. Cardiac magnetic resonance angiography and echocardiography showed a large pseudoaneurysm with a neck of approximately 24 mm, and a high velocity bi-directional jet between the posterolateral wall of the left ventricle (LV) and a vast sump. Hand contrast angiography together with conventional angiography confirmed a communication between the LV cavity and a large false cavity. A trans-septal catheterization was deemed suitable as the delivery catheter length would preclude a femoral arterial approach. Results: A 24 mm Amplatzer sizing balloon was advanced into the pseudoaneurysm cavity which sized the orifice at 22 mm. A 10 French Amplatzer sheath was passed through the defect and a 26 mm Amplatzer septal occluder was deployed across the defect (1F). We noticed a collapse in the center of the discus deployed on the ventricular site suggesting that the design of the device may not be strong enough to withstand the pressure difference. Upon release of the delivery system, the device was dislocated. We attempted to retrieve the device with a snare catheter but we were unsuccessful. Afterwards the patient was given to surgery for device removal, and pseudoaneurysm resection. Unfortunately he died during early post-operative period. Conclusions: The novel and important aspects of our intervention is that a femoral vein approach with trans-septal puncture is safe and effective for percutaneous closure of a left ventricular pseudoaneurysm. We recommend a gentile Minnesota maneuver to be employed just to make sure releasing the delivery system is safe. A different Amplatzer device with a more robust design on one discus, which would be deployed on the ventricular site could be more appropriate for closure of a larger left ventricular pseudoaneurysm.

Successful Resection of a Giant Left Ventricular Pseudoaneurysm Developed Later after Mitral Valve Replacement

We present a case of successful surgical resection of a giant left ventricular (LV) pseudoaneurysm that developed 5 yr after mitral valve replacement (MVR). A 59-yr-old female was admitted with exertional chest pain radiating to left arm and back. 64-slice multidetector computed tomography (MDCT) revealed significant stenosis on the ostium of the first diagonal branch of the left anterior descending coronary artery and also a huge pseudoaneurysm compressing the right atrium and the inferior vena cava. She underwent resection of the pseudoaneurysm, and the pseudoaneurysm tunnel was repaired from the inside of LV cavity by removing the previously inserted prosthetic valve, followed by redo MVR together with coronary arterial bypass grafting (CABG) for a single-vessel disease. At the 6-month follow-up, the patient continued to do well without any complications.

Recurrent Coarctation: Is Surgical Repair of Recurrent Coarctation of the Aorta Safe and Effective?

Persistence or recurrence of stenosis is a complication of coarctation repair and is associated with major long-term morbidity. The rate of recurrence varies significantly, depending on the age of the patient, technique at initial repair, and the arch anatomy. We reviewed our experience with surgical repair of recurrent coarctation of the aorta and compared it with our institutional experience with balloon aortoplasty. We retrospectively reviewed our experience with 1,012 patients undergoing initial repair of coarctation between 1960 and 2008. During that time, 103 patients (10%) required reintervention. Median age at reintervention was 6.5 years (range, 2 weeks to 44 years) and median weight was 12 kg (range, 1.9 to 94 kg). Fifty-nine patients with recoarctation had surgical repair, and 44 patients were treated with balloon aortoplasty with or without stent placement. Ninety-five percent of patients have been followed up (median time, 14.2 years; range, 2 months to 42 years). There were 5 late deaths. Actuarial survival was 98% at 15 and 40 years in patients with surgical reintervention, and it was 91% (p = 0.001) at 15 years in patients with balloon aortoplasty reintervention. A second redo coarctation of the aorta reintervention was performed in 12 patients: 8 patients after percutaneous intervention (nonsurgical) and 4 patients after surgical recoarctation repair. The median interval between first and second reintervention was 3.5 years (range, 1 month to 14 years). One patient who had two dilations underwent a third and fourth reintervention: patch enlargement and pseudoaneurysm resection. Freedom from reintervention in the surgical group was 96% at 15 years and 94% at 40 years, which was compared with actuarial freedom from reintervention for patients with percutaneous intervention (balloon/stent) at 15 years (82%; p < 0.001). Our study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. The recurrence after surgical reintervention is low, and most patients to date have not required further intervention. Balloon aortoplasty as an alternative method of managing recoarctation is efficient and less invasive than surgery; however, well-described complications may occur. Recurrence rates with angioplasty are significantly higher than with surgery.

Silver-coated dacron prosthesis in the treatment of infection in arterial surgery: Case reports

Although the incidence is low, infection of prosthetic vascular graft bears a high incidence of serious complications including 25-75% mortality rate and 40-75% limb loss. The standard treatment of vascular graft infection consists of excision of the prosthesis, wound debridement and extraanatomic revascularization. Conservative treatment might be an option in a limited number of patients. We present three cases of surgical and conservative treatment of vascular graft infection. Case 1: A patient developed silver-coated graft infection after femorodistal arterial reconstruction performed because of critical limb ischemia. In the early postoperative period, massive skin and subcutaneous tissue necrosis developed, with the graft being exposed. After two months of persistent debridement and wound toilette, the defect was covered with aThiersch skin graft. Case 2: PTFE graft infection in the right groin followed reconstruction of the isolated common femoral artery aneurysm. This graft was replaced with a silver-coated graft in situ. Reinfection of the proximal end of the implanted silver-coated graft occurred and the graft was exposed. After repeated debridement and wound toilette, the exposed prosthesis was covered with granulomatous tissue, and the wound healed. Case 3: A year after anastomotic pseudoaneurysm resection in the left groin, prosthesis was exposed following wound infection. This graft was substituted with a silver-coated graft in situ. The wound healed primarily. These three cases demonstrate that under some circumstances vascular prosthesis infection can be successfully treated conservatively without graft removal, and also by in situ replacement using silver-coated graft.

Off-Pump Resection of Aorto-Saphenous Vein Graft Pseudoaneurysm

Pseudoaneurysms of saphenous vein grafts are rare. We present the case of a 58-year-old man who presented with recurrent angina nine years following quadruple coronary artery bypass graft surgery in 1983. He was found to have an aneurysm arising from the ascending aorta. The patient underwent off-pump aorto-saphenous vein pseudoaneurysm resection and redo coronary artery bypass grafts.

Anastomotic pseudoaneurysms

Anastomotic pseudoaneurysm is a form of false aneurysm, whose wall does not consist of all normal layers of arterial wall. Given the rising number of reconstructive vascular procedures, the increase of anastomotic pseudoaneurysm cases is expected. Therefore, identification of causes, clinical manifestations as well as factors which affect the outcome of operative treatment of anastomotic pseudoaneurysms is of great practical value. This retrospectively-prospective study included 87 surgically treated cases of anastomotic pseudoaneurysms in the period from 1991 to 2002. The most often localization of anastomotic pseudoaneurysms was the inguinal region (68-86.2%). In the majority of cases, they were caused by arterial degeneration in the anastomotic region--56 cases (65.9%) and infection--21 cases (24.7%). The most frequent manifestations of anastomotic pseudoaneurysms were bleeding due to rupture in 26 cases (29.9%) and chronic limb ischaemia in 22 cases (25.3%). An acute limb ischaemia was present in 17 cases (19.5%), the symptoms caused by local compression to the surrounding structures--in 9 cases (10.3%), and in 12 cases (13.8%), the only manifestation of anastomotic pseudoaneurysm was asymptomatic pulsatile mass. In 32 cases (36.8%), surgical treatment involved the resection of anastomotic pseudoaneurysm and graft interposition, whereas in 39 cases (44.8%), bypass procedure had to be performed after the resection. Comorbidity significantly increased mortality in the first 30 days. The use of Dacron graft in primary operation significantly improved early results of operative treatment. Absence of infection as the cause of anastomotic pseudoaneurysm is a statistically important prognostic factor of operative treatment, considering the graft patency, limb salvage, infection, need for reintervention and mortality.

Mycotic innominate artery pseudoaneurysm presenting as an embolic stroke

Clinical Summary A 62-year-old man presenting with hoarseness was diagnosed with a squamous epithelial cell tumor of the soft palate. He underwent soft palate resection with adjuvant localized radiation therapy. After he was free of recurrence during the ensuing 5 years, osteoradionecrosis of the medial left clavicle and a corresponding methicillin-resistant Staphylococcus aureus (MRSA) infection involving the sternoclavicular joint developed. This was successfully treated with intravenous antibiotics, surgical debridement, and coverage with a left pectoralis muscle rotation flap. Four months after being treated for this infection, the patient had an embolic cerebrovascular accident localized to the right middle cerebral artery territory, as determined by magnetic resonance imaging, and this manifested as a left-sided hemiparesis. Incidentally, magnetic resonance imaging also revealed a 3.6 3.4-cm saccular pseudoaneurysm with a narrow 5-mm neck emanating from the anterior base of the innominate artery (Figure 1) and extensive inflammatory soft tissue in the anterior mediastinum extending from the left distal clavicle to the innominate, subclavian, and common carotid arteries. The results of blood cultures were positive for MRSA, and intravenous vancomycin was initiated. Because the results of additional diagnostic studies, including a carotid Duplex ultrasound and cardiac echocardiogram, were unremarkable, the most plausible source of this embolic stroke was ascribed to the pseudoaneurysm. Because of the perceived risk of further embolic stroke and risk of rupture, pseudoaneurysm resection was recommended. Surgical resection was performed 2 weeks after the cerebrovascular accident and after near-complete recovery of left-sided motor function. At the time of the operation, the innominate artery pseudoaneurysm was identified through a standard median sternotomy approach (Figure 2). During the dissection, moderate inflammatory tissues were encountered in the vicinity of the aortic arch in continuity with the left sternoclavicular region, although no gross purulence was noted. Cardiopulmonary bypass was instituted with aortic cannulation of the distal ascending aorta and dual-staged venous cannulation of the right atrium. With the use of deep hypothermic circulatory arrest, the pseudoaneurysm was dissected circumferentially and opened. Substantial thrombus was removed from the saccular component of the pseudoaneurysm, revealing a narrow neck arising approximately 8 mm distal to the origin of the innominate artery. After the pseudoaneurysm was completely resected, the resultant 1-cm defect at the base of the innominate artery was repaired with a patch of autologous pericardium fixed in glutaraldehyde. A 28-minute period of circulatory arrest was required. The results of intraoperative cultures and histologic analyses of the pseudoaneurysm and surrounding mediastinal tissues were negative for active infection or neoplasm. The patient was discharged to home after an unremarkable 7-day postoperative course to complete a 6-week course of MRSAspecific intravenous antibiotics.

Basilic vein transposition: an underused autologous alternative to prosthetic dialysis angioaccess

Purpose: Provision of lifelong angioaccess for hemodialysis generally requires multiple procedures. To extend the availability of each extremity as an access site, we have used the transposed basilic vein for fistula construction since 1988. Our purpose is to present our initial experience, with follow-up of 30 months.Methods: We have used the transposed proximal basilic vein in 65 procedures to construct an autogenous arteriovenous fistula (AVF) to the brachial artery in 58 patients without suitable superficial venous anatomy. There were 25 males and 33 females, with a mean age of 47 years (range 10 to 77). The basilic vein transposition was the initial angioaccess procedure in only 25% of cases and secondary in 75%. Three additional patients underwent exploration of an inadequate basilic vein with subsequent prosthetic grafting.Results: There were no operative deaths. Two postoperative complications included a wound infection and a transient steal syndrome. The actuarial life-table patency rate for all successfully completed AVFs was 49% at 30 months. Late revisions with continued patency were required in 11 cases, including repair of a focal stenosis in six, pseudoaneurysm resection in two, and thrombectomy in one. Sixty-seven percent of patients who required subsequent prosthetic grafting for a failed basilic vein AVF had an ipsilateral procedure. Patient preference for the opposite arm was the usual indication for contralateral grafting in the remainder.Conclusions: The transposed basilic vein AVF was technically feasible in 95% of cases, can frequently be performed in patients with multiple previous access procedures, does not compromise the arm for future prosthetic grafting, and has a long-term patency rate that is comparable to more traditional autologous AVFs. This underused procedure should be considered before placement of polytetrafluoroethylene graft for long-term angioaccess.

Vascular trauma as a result of therapeutic procedures for the treatment of malignancy

Twenty-two iatrogenic vascular injuries caused by resection of tumors with local recurrences or adjuvant chemotherapy were treated over a 42-month period in 11 female and 8 male patients with cancer (58% had documented metastases). Sixteen of 22 vascular injuries were caused by intraarterial administration of chemotherapy (8 emboli; 8 direct catheter trauma), and six were caused by resection of tumors with local invasion. The injuries were extremity ischemia (15 extremities in 13 patients), pseudoaneurysm (4), expanding hematoma (3 injuries in 2 patients). Twenty-two surgical repairs included bypass of severely damaged arteries in five, embolectomy in five, interposition grafts in three, pseudoaneurysm resection and primary repair in three, primary repair of three vascular injuries, and one patch angioplasty. Leg amputation was required in two patients. Seventeen of 19 patients had successful vascular repairs with resolution of preoperative indications for vascular repair without intraoperative or postoperative deaths. Long term follow-up (mean, 17 months) showed no recurrence of vascular problems; however, two patients died of metastatic cancer at 6 and 24 weeks after vascular repair. This study supports an aggressive approach to the management of vascular injuries caused by therapeutic interventions for malignancy despite the presence of metastatic disease.

Routine revascularization with resection of infected femoral pseudoaneurysms from substance abuse

Infected femoral artery pseudoaneurysms in narcotic addicts present challenging management options. Our policy of routine revascularization is based on the concern that a high rate of amputations must follow ligation and resection alone or with selective delayed revascularization. Fifteen of 16 patients with infected pseudoaneurysms of femoral arteries, treated with resection and bypass grafts, were observed from 1 to 44 months. Obturator bypass grafts were used in 10 patients, iliac-femoral grafts in three, axillopopliteal in one, and right external iliac crossover to left popliteal in one patient. One limb, unsalvageable at presentation, was amputated primarily, along with resection of pseudoaneurysm and femoral artery ligation, without bypass grafting. One iliac-femoral graft became infected and then thrombosed 4 months after operation. Unsuitable distal arteries and impending necrosis led to above-knee amputation. One late failure among 15 revascularization attempts (7%) is significantly lower than the 11% to 33% amputation rates reported in the literature with resection of pseudoaneurysm alone and delayed selective revascularization. The other 14 patients had functioning limbs without claudication or rest pain. Our experience indicates that revascularization at the time of resection of infected pseudoaneurysm offers better prospects for limb salvage.

Arterial insufficiency in hemodialysis access procedures: Reconstruction by an interposition polytetrafluoroethylene graft conduit

The interposition polytetrafluoroethylene graft conduit has found many uses in the armamentarium of the surgeon who performs vascular access for hemodialysis: when resection of aneurysm or pseudoaneurysm is required, or when an extension loop is required, either to simply lengthen the amount of graft or to circumvent an infected segment after resection.