520852 research-article2014
PRF0010.1177/0267659114520852PerfusionAl-Atassi et al.
Case Report
A novel approach to safe redo-sternotomy in a patient with aortocutaneous fistula from an infected ascending aorta graft
Perfusion 2014, Vol. 29(4) 373–374 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114520852 prf.sagepub.com
T Al-Atassi,1 DM Kimmaliardjuk,2 M Labinaz,3 S Dickie4 and F Rubens1
Abstract This case describes a novel approach to a safe redo-sternotomy in a patient presenting with an aortocutaneous fistula from a previous infected ascending aorta graft. Keywords aortocutaneous fistula; redo-sternotomy; ascending aorta replacement; axillary; catheter
Case Report A 76-year-old man who had undergone repair of a Stanford type A aortic dissection presented seven years later to his family doctor with a three-week history of an enlarging pulsatile swelling over the lower manubrium. An urgent computed tomography scan of the chest was obtained, showing a fistula eroding from the ascending aortic graft through the manubrium and into a collection in the subcutaneous tissue. There was also a collection of fluid contiguous to the leak, measuring 3.2 x 1.1 cm. An echocardiogram revealed moderate aortic insufficiency. As there was a high risk for exsanguination with re-sternotomy, a strategy was devised to decompress the aorta and provide optimal myocardial protection. Arterial inflow and venous return for cardiopulmonary bypass was provided through the right axillary artery and the right femoral vein, respectively. A left ventricular vent was inserted through the apex via a mini-thoracotomy. An 8 mm Gelsoft tube graft (Vascutek, Inchinnan, Renfrewshire, Scotland) was anastomosed onto the left axillary artery and a second 8 mm Gelsoft tube graft was anastomosed as an end-toside anastomosis to the first tube graft, creating a Y configuration (Figure 1A). One-way valve catheter introducers (8 French Pinnacle Sheaths, Terumo Medical Corp., Elkton, MD) were introduced and secured in each arm of the Y-graft (Figure 1A). Through the two arms of the Y-graft, two guide wires (0.035 inch Amplatz extra stiff and 0.035 inch fixed core wire safe-TJ, Cook Medical Inc., Bloomington, IN) were positioned in
the aortic root under fluoroscopic guidance. The first was used to place an 8 French EBU 3.5 launcher guiding catheter (Medtronic, Minneapolis, MN) in the aortic root for cardioplegia administration and the second was used to position a 34 mm Amplatzer Sizing Balloon II (AGA Medical Corp., Plymouth, MN) in the distal ascending aorta (Figure 1B). Cardiopulmonary bypass was initiated, with immediate cooling to 28 degrees Celsius. The balloon in the distal ascending aorta was inflated and antegrade cardioplegia was provided through the root cannula. In order to ensure that the balloon remained in the proper position during cardioplegia administration, an epicardial fibrillator was used to induce ventricular fibrillation immediately prior to 1Division
of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada 2University of Calgary, Calgary, Canada 3Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada 4Division of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Canada Corresponding author: Fraser Rubens University of Ottawa Heart Institute 40 Ruskin Street Suite 3401, Ottawa Ontario, K1Y 4W7 Canada. Email: [email protected]
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Perfusion 29(4)
the graft to the arch. During further cooling, the aortic valve was replaced with a bioprosthesis (Trifecta 23 mm, St. Jude Medical, St. Paul, MN). When the target temperature was achieved, the balloon was deflated and removed and a short period of circulatory arrest was used to complete the distal anastomosis to the arch (30 mm Gelsoft tube graft), maintaining antegrade cerebral perfusion with right axillary perfusion. After clamping the graft, rewarming was initiated and the proximal anastomosis was completed to the native aorta at the level of the sinotubular junction. After coming off bypass and administering protamine, a tongue of omentum was wrapped around the new aortic graft.
Discussion Aortic graft infection is a serious complication. There is only sparse data and no consensus on management guidelines of aortic graft infections.¹ Mortality and morbidity from infected grafts is high,¹ but the mortality rate is lower if intervention is undertaken before rupture.² The challenge in this case was the potential for exsanguination with direct sternotomy. The simple construction of a Y-graft onto the left axillary artery enabled simultaneous placement of an endoluminal balloon to decompress the aorta as well as administration of antegrade cardioplegia. This novel approach allowed for a safe sternotomy and exposure of the ascending aorta with minimal bleeding. In summary, Y-graft construction to the axillary artery can be a useful approach in patients in whom a direct sternotomy risks major bleeding or exsanguination. Figure 1. (A) Operative picture showing the Y-graft anastomosed to the left axillary artery with two one-way valve catheters placed in preparation for cardioplegia catheter and balloon insertion (I), the presenting subcutaneous collection or “bulge” (II), the cardiopulmonary bypass arterial cannulation through a straight 8 mm tube graft sewn onto the right axillary artery (III) and the mini thoracotomy used for placing the left ventricular vent (IV). (B) Still fluoroscopic image of the 34 mm balloon deployed in the distal ascending aorta proximal to the innominate artery (I) and the aortic root catheter delivering antegrade cardioplegia (II).
balloon inflation. After achieving asystole, redo sternotomy was accomplished. The balloon had completely decompressed the root and there was a 1 cm hole in the anterior aspect of the ascending aortic graft, with evidence of infection extending along the entire length of
Declaration of conflicting Interest The authors have no conflicts of interest to declare.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Yamashita S, Dohi T, Shimizu Y, et al. Aortopulmonary fistula caused by an infected thoracic aortic false aneurysm rupturing after endovascular stent placement. Drug Discov Ther 2012; 6: 278–282. 2. Ando Y, Kurisu K, Hisahara M, Mashiba K, Maeda T. Multiple infected aortic aneurysms repaired by staged in situ graft replacement. Ann Thorac Cardiovacs Surg 2010; 16: 60–62.
Downloaded from prf.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on March 13, 2015
PRF0010.1177/0267659114520852PerfusionAl-Atassi et al.
Case Report
A novel approach to safe redo-sternotomy in a patient with aortocutaneous fistula from an infected ascending aorta graft
Perfusion 2014, Vol. 29(4) 373–374 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114520852 prf.sagepub.com
T Al-Atassi,1 DM Kimmaliardjuk,2 M Labinaz,3 S Dickie4 and F Rubens1
Abstract This case describes a novel approach to a safe redo-sternotomy in a patient presenting with an aortocutaneous fistula from a previous infected ascending aorta graft. Keywords aortocutaneous fistula; redo-sternotomy; ascending aorta replacement; axillary; catheter
Case Report A 76-year-old man who had undergone repair of a Stanford type A aortic dissection presented seven years later to his family doctor with a three-week history of an enlarging pulsatile swelling over the lower manubrium. An urgent computed tomography scan of the chest was obtained, showing a fistula eroding from the ascending aortic graft through the manubrium and into a collection in the subcutaneous tissue. There was also a collection of fluid contiguous to the leak, measuring 3.2 x 1.1 cm. An echocardiogram revealed moderate aortic insufficiency. As there was a high risk for exsanguination with re-sternotomy, a strategy was devised to decompress the aorta and provide optimal myocardial protection. Arterial inflow and venous return for cardiopulmonary bypass was provided through the right axillary artery and the right femoral vein, respectively. A left ventricular vent was inserted through the apex via a mini-thoracotomy. An 8 mm Gelsoft tube graft (Vascutek, Inchinnan, Renfrewshire, Scotland) was anastomosed onto the left axillary artery and a second 8 mm Gelsoft tube graft was anastomosed as an end-toside anastomosis to the first tube graft, creating a Y configuration (Figure 1A). One-way valve catheter introducers (8 French Pinnacle Sheaths, Terumo Medical Corp., Elkton, MD) were introduced and secured in each arm of the Y-graft (Figure 1A). Through the two arms of the Y-graft, two guide wires (0.035 inch Amplatz extra stiff and 0.035 inch fixed core wire safe-TJ, Cook Medical Inc., Bloomington, IN) were positioned in
the aortic root under fluoroscopic guidance. The first was used to place an 8 French EBU 3.5 launcher guiding catheter (Medtronic, Minneapolis, MN) in the aortic root for cardioplegia administration and the second was used to position a 34 mm Amplatzer Sizing Balloon II (AGA Medical Corp., Plymouth, MN) in the distal ascending aorta (Figure 1B). Cardiopulmonary bypass was initiated, with immediate cooling to 28 degrees Celsius. The balloon in the distal ascending aorta was inflated and antegrade cardioplegia was provided through the root cannula. In order to ensure that the balloon remained in the proper position during cardioplegia administration, an epicardial fibrillator was used to induce ventricular fibrillation immediately prior to 1Division
of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada 2University of Calgary, Calgary, Canada 3Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada 4Division of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Canada Corresponding author: Fraser Rubens University of Ottawa Heart Institute 40 Ruskin Street Suite 3401, Ottawa Ontario, K1Y 4W7 Canada. Email: [email protected]
Downloaded from prf.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on March 13, 2015
374
Perfusion 29(4)
the graft to the arch. During further cooling, the aortic valve was replaced with a bioprosthesis (Trifecta 23 mm, St. Jude Medical, St. Paul, MN). When the target temperature was achieved, the balloon was deflated and removed and a short period of circulatory arrest was used to complete the distal anastomosis to the arch (30 mm Gelsoft tube graft), maintaining antegrade cerebral perfusion with right axillary perfusion. After clamping the graft, rewarming was initiated and the proximal anastomosis was completed to the native aorta at the level of the sinotubular junction. After coming off bypass and administering protamine, a tongue of omentum was wrapped around the new aortic graft.
Discussion Aortic graft infection is a serious complication. There is only sparse data and no consensus on management guidelines of aortic graft infections.¹ Mortality and morbidity from infected grafts is high,¹ but the mortality rate is lower if intervention is undertaken before rupture.² The challenge in this case was the potential for exsanguination with direct sternotomy. The simple construction of a Y-graft onto the left axillary artery enabled simultaneous placement of an endoluminal balloon to decompress the aorta as well as administration of antegrade cardioplegia. This novel approach allowed for a safe sternotomy and exposure of the ascending aorta with minimal bleeding. In summary, Y-graft construction to the axillary artery can be a useful approach in patients in whom a direct sternotomy risks major bleeding or exsanguination. Figure 1. (A) Operative picture showing the Y-graft anastomosed to the left axillary artery with two one-way valve catheters placed in preparation for cardioplegia catheter and balloon insertion (I), the presenting subcutaneous collection or “bulge” (II), the cardiopulmonary bypass arterial cannulation through a straight 8 mm tube graft sewn onto the right axillary artery (III) and the mini thoracotomy used for placing the left ventricular vent (IV). (B) Still fluoroscopic image of the 34 mm balloon deployed in the distal ascending aorta proximal to the innominate artery (I) and the aortic root catheter delivering antegrade cardioplegia (II).
balloon inflation. After achieving asystole, redo sternotomy was accomplished. The balloon had completely decompressed the root and there was a 1 cm hole in the anterior aspect of the ascending aortic graft, with evidence of infection extending along the entire length of
Declaration of conflicting Interest The authors have no conflicts of interest to declare.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Yamashita S, Dohi T, Shimizu Y, et al. Aortopulmonary fistula caused by an infected thoracic aortic false aneurysm rupturing after endovascular stent placement. Drug Discov Ther 2012; 6: 278–282. 2. Ando Y, Kurisu K, Hisahara M, Mashiba K, Maeda T. Multiple infected aortic aneurysms repaired by staged in situ graft replacement. Ann Thorac Cardiovacs Surg 2010; 16: 60–62.
Downloaded from prf.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on March 13, 2015
