Keywords
interrupted aortic arch - congenital cardiac surgery - pericardial roll
Interrupted aortic arch is a rare congenital cardiac pathology that requires emergency
repair during infancy. Different techniques, such as aortic mobilization and ascending
aorta to descending aorta anastomosis, patch augmented anastomosis, or biologic or
synthetic graft interposition, have been described in the literature for the treatment
of this pathology.[1]
The patient is a 3-year-old boy who underwent autologous pericardial tube graft interposition
between the ascending and descending aorta for the treatment of Type B interrupted
aortic arch during infancy. He had two insignificant apical muscular ventricular septal
defects that did not require closure or pulmonary artery banding.
He has been followed periodically in the outpatient clinic, and the ventricular septal
defects closed spontaneously. However, the pericardial roll dilated gradually. Originally
it was 7 mm in diameter, and the size enlarged to 1.5 to 2.4 to 3.1 and finally 4.2 cm
in diameter at 12, 18, 28, and 36 months, respectively.
Aneurysm formation was confirmed with computed tomography (CT) angiography that revealed
a 4.2-cm dilatation of the pericardial tube ([Fig. 1A], [B], [Video 1]). There was a stenosis visualized at the proximal anastomosis region. However, cardiac
catheterization did not indicate a significant gradient ([Fig. 2A], [B], [Video 2]).
Fig. 1 Axial (A) and 3-dimentional (B) computerized tomography angiography reveals dilatation of the pericardial tube.
Video 1 Three-dimensional computerized tomography angiography video.
Fig. 2 Preoperative cardiac catheterization: saggital (A) and frontal (B) view.
Video 2 Cardiac catheterization video.
We performed surgical reconstruction of the aortic arch. The anterior wall of the
aneurysm was resected leaving the posterior wall to enable growth. Reconstruction
was done with a xenograft pericardial patch (Edwards Lifesciences, Irvine, CA). Operative
and postoperative courses were uneventful. This patient was discharged on postoperative
day 5. He remains asymptomatic, without evidence of further aortic dilatation for
more than 12 months.
The reason for occurrence of the pericardial roll autograft aneurysm was attributed
to the fresh use of the pericardial material and stenosis at the proximal anastomosis
zone, that is, poststenotic dilatation. The advantages of pericardial roll bypass
technique includes protecting the patient from negative effects of cardiopulmonary
bypass, providing relatively shorter operation time and growth potential due to use
of native tissue. However, while fresh materials may cause graft aneurysm, in the
condition of longer gluteraldehyde fixation, calcification may occur and the growth
potential may be compromised. Also, xenografts may be calcified. The appropriate fixation
of the pericardium as a native tissue is beneficial to prevent complications. Complications
including aneurysm, infection, or calcification have been reported in the literature
by different authors following pericardial tube into position.[2] In complicated and life-threatening cases, resection of the pericardial materials
and reconstruction of the remaining anatomy has been performed.[3] Autologous pericardial tube aneurysm after aortic interruption repair is possible
but very rare. Treatment is required when symptoms of compression of the adjacent
structures and progressive enlargement of the aneurysm occur.
As a limitation, we did not have a postoperative control CT, the patient was followed-up
with echocardiography to prevent negative effects of CT such as radiation and contrast.
If we had any doubts about gradient or dilatation, we were going to perform CT. But
the patient was followed-up uneventfully.
