Late Giant Aortic Pseudoaneurysm Following Iatrogenic Aortic Dissection

Abstract

Aortic pseudoaneurysm occurs in 10 to 24% of patients after acute type A aortic dissection repair. We report the case of a 72-year-old female who developed an intraoperative iatrogenic ascending aortic dissection following mitral valve repair. A giant ascending aortic pseudoaneurysm was detected on follow-up imaging. This case emphasizes the importance of close radiological surveillance following acute aortic dissection repair.

 

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Keywords

aorta - acute aortic dissection - aortic pseudoaneurysm - imaging - surveillance

A 72-year-old female with a medical history of hypertension, interstitial lung disease, and obstructive sleep apnea underwent elective mitral valve repair for posterior leaflet prolapse using a 30-mm MitroFix™ device. The aortic root and ascending aorta had normal dimensions. Following removal of the aortic root vent on discontinuation of cardiopulmonary bypass, a bluish discoloration of the ascending aorta was evident, with visible ascending aortic dilatation. Transesophageal echocardiography confirmed an acute DeBakey type II aortic dissection. Ascending aortic replacement was therefore performed using a 26-mm Gelweave™ (Terumo UK Ltd.) interposition graft with 4/0 polypropylene suture under hypothermic circulatory arrest at 18 °C alongside antegrade cerebral perfusion. The patient made an uncomplicated recovery and was discharged home.

Three months postoperatively, the patient reported progressive dyspnea, prompting a transesophageal echocardiogram. This demonstrated preserved biventricular function, mild central aortic regurgitation, trace mitral regurgitation, and an intact ascending aortic graft. Chest X-ray ([Fig. 1]) revealed widened mediastinal appearances and small bilateral pleural effusions. Her respiratory symptoms at this stage were attributed to preexisting pulmonary disease.

Fig. 1 Chest X-ray demonstrating mediastinal widening 3 months postoperatively.

With further symptomatic deterioration at 6 months postoperatively, transthoracic echocardiography demonstrated an ascending aortic pseudoaneurysm measuring 8.1 cm. Urgent computed tomography angiogram of the aorta ([Figs. 2] [3] [4]) revealed a giant aortic pseudoaneurysm arising just superiorly to the right coronary ostium via a 2.4-cm orifice and measuring 8.2 cm in maximal cranio–caudal dimension.

Fig. 2 Coronal computed tomography scan demonstrating a giant aortic pseudoaneurysm (asterisk) arising from just above the right coronary ostium.

Fig. 3 Axial computed tomography scan demonstrating the giant aortic pseudoaneurysm (asterisk).

Fig. 4 Three-dimensional computed tomography scan demonstrating the aortic pseudoaneurysm.

The patient underwent an emergency redo sternotomy for resection of the pseudoaneurysm and replacement of the aortic root using a Freestyle® (Medtronic, Inc.) prosthesis. She unfortunately succumbed postoperatively to severe bleeding complications in the intensive care unit.

Aortic pseudoaneurysms may develop in 10 to 24% following surgery for acute Type A aortic dissection[1] and predispose to dissection, rupture, and embolization. In retrospect, however, our patient's postoperative presentation with dyspnea may well have been a manifestation of the enlarging pseudoaneurysm's compressive effects on adjacent lung parenchyma or cardiac structures. We propose that localized infection or an intraoperatively undetected technical issue involving the proximal anastomosis adjacent to the right coronary ostium may potentially have induced pseudoaneurysm formation in this case. Special attention must be paid to the critical technical aspects of dissection repair, particularly the meticulous performance of anastomoses in fragile tissues, and imperfections that can risk delayed suture line dehiscence. While successful percutaneous repair of aortic pseudoaneurysms has been reported,[2] an open surgical approach was planned for our patient owing to the large size of the pseudoaneurysm, its broad neck, and proximity to the right coronary ostium.

The present case highlights the importance of close postoperative surveillance with periodic cross-sectional imaging at intervals specified by departmental protocols, or sooner on clinical or radiological suspicion of an adverse event, to permit the timely identification and optimal management of aortic complications.

 

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Conflict of Interest

None declared.

• References

• 1 Chaud GJ, Mohammadi S, Cervetti MR. et al. Aortic pseudoaneurysm after type a aortic dissection: results of conservative management. Semin Thorac Cardiovasc Surg 2023; 35 (03) 457-464
• 2 García E, Unzué L, Fernández López-Peláez MS. Percutaneous closure of an ascending aortic pseudoaneurysm. Rev Esp Cardiol (Engl Ed) 2015; 68 (12) 1176

Publication History

Received: 12 February 2024

Accepted: 06 November 2024

Article published online:
03 March 2025