45
Aorto-cutaneous Fistula: A Rare Complication ofAortic Surgery B. 1. M. Bridgewater, V Tsang, 1. Pepper, and S. C. Lennox Department ofCardiothoracicSurgery, Royal Brompton National Heart and LungHospitals Fulham Road, London, Great Britain
Two cases of false an eur ysm of the as cending aorta which pr esented with discharge of arter ial blood from a stern al wound ar e discuss ed. The first presented 8 years after aorti c valve surgery and was diagnos ed by contrast enhanced computerised tomograph y of the th orax . The seco nd pr esent ed 6 month s following repair of an aortic diss ection and the dia gnosis was confirmed by thoracic magnetic resonan ce imaging. The diagnosis and surgical man agement of th ese cases ar e reviewed . Keywo rds
Aorto-kutane Fistel: Eine seltene Komp likation der Aortenc hir urgie Es wird tiber zwei Faile eines falschen Aneurysmas der Aorta ascendens berichtet, die sich dur ch den Ausstrom von arteriellem Blut aus einer Sternumwunde bemerkbar ma chten . 1m ersten Fall tr at das Ere ignis 8 Jahre na ch einem Aortenklappe ners atz auf, die Diagn ose konnt e mit Hilfe eines Kontrast- CTs gestellt werden . 1m zweiten Fall wurde 6 Monate zuvor eine Aortendisse ktion korri giert, hier wur de die Diagnose anha nd eines NMR des Thorax best atigt, Die Diagnose un d das chiru rgische Vorgehe n in beiden Fallen wird erortert.
Aorto-cuta neo us fistula - Cardiac surgery - Computerised tomography - Magnetic resonan ce imaging
Introduction Fals e aneurysm of th e as cending aorta, a rare complication of cardiac surger y, has been reported as arising from th e aortic cannulation site (2), needle puncture sites, and the aortic suture line (11). The pr esentation of a false an eurysm as an aorto-cutaneous fistula has not been previously described. Two such cases pr esented to our institution between 1988 and 1990.
aortic suture line. The defect was closed with two interrupted suture s of 2/0 pr olen e, th e pati ent came ofT bypass well, th e sternum was debrid ed and all infected mat erial rem oved. She mad e a sa tisfactory haemodynam ic recovery but developed a left-sided weakn ess which resolved during her hospit al stay. She was dis charge d to convalesce nce 3 weeks after surgery.
Case Rep orts Case I : A 78-year-old lad y, who had had an aortic valve replacement 10 years pr eviously, had a three year hist ory of chronic discha rge from sinuses in her stern al wound. She pr esent ed with a brisk discharge of fresh blood through a sinus . An aorto-cutaneo us fistula was suspected. Computeris ed tom ography of the th orax showed an extensive density conta ining some calcification to the left sid e of th e asce nding aorta, just sup erior to th e aortic root (Fig. 1). This lesion enhanced following administration of intravenous contrast suggesting an an eurysm (Fig. 2). At operation, a technique was employed to ena ble circulatory arrest to be used should severe bleeding occur (5). Femora-femoral bypass was esta blishe d and th e patient was cooled . When the core temperatur e reached 30 °C the sternum was care fully opened whilst th e temp erature was allowed to go lower. When it becam e appa re nt that circulat ory arrest was not necessary. she was rewarmed to 28 °C. A small, well-dema rcate d bleedin g point wa s pr esent in a false ane urysm at the pulmonary artery end of th e
Thorac. cardiovasc. Surgeon 40 (1992) 45-47 © Georg Thieme Verlag Stuttgart · New York
Fig. 1 Case 1. CTscanof thethoraxdemonstrates anextensivedensityonthe left side of the ascending aorta,just superior to theaortic root
Received for Publication: Septe mber 2, 199 1
Downloaded by: NYU. Copyrighted material.
Summary
Thom e. eardiovase . Surgeon 40 (1992)
B. 1. M. Bridgewater. V. Tsang. J. Pepp er. and S. C. Lennox
gra ft from the long saphenous vein was anas tomosed between the distal right coronary artery and the anterior asp ect of th e Dacr on graft. The grea ter omentum was mobilised and inserted into the chest anterior to the graft. Postoper atively he developed a sever e wound infection which requir ed fur ther surgical debridem ent and the placement of a free left latissimus dorsi muscle flap . He mad e a slow but satisfactory recovery and was discharg ed to home six weeks following his admission. He was alive and well when we last saw him .
Discussion
Fig.2 Case 1.The lesion shownin Fig. 1 has enhanced followingintra-venous injection of contrast
Fig. 3 Case 2. Magnetic resonance imagingof thethorax shows theaortic archto bedilated,withafalselumen containingclotted blood.Thereisalsoan extensive soft tissue mass lying anteriorlyto the ascendingaorta
Case 2: A 60-year -old man was transferred to our hospital 6 month s following an aortic dissection for which he had had a Dacron gra ft insert ed into his asce nding aorta . Postoperatively he had developed a severe stern al wound infection which required exte nsive surgery to excise his sternum and mobilise muscle flaps from both pectorals and the right rectus shea th. He mad e a good recovery from this initial opera tion. Sever al days pri or to his tr an sfer to us he had episodes of bright red blood bleedin g from a sinus at the lower end of his sternal wound. An aorto-cuta neous fistula was again suspec ted. Magnetic resonan ce imaging of the thorax sh owed the aortic arch to be dilated, with a false lumen contai ning blood clot. There was an extensive soft tissue mass lying anterio rly to the asce nding aor ta (Fig. 3). A coronary arteriogra m revealed a 70 % stenos is of the right corona ry arte ry. A similar surgical techniqu e to the previous case was used. Femoro-fem oral bypass was estab lished and the patient was slowly cooled. The anterior ches t wall was opened in the midline. Ther e was a lar ge amount of infected material assoc iated with a false ane urys m on th e anter ior aspect of the aorta. The patient was cooled to 18 °C and the circulation was arres ted . The infected Dacron gra ft was re moved along with all othe r infected material. A 'Gelsea l' Dacron gra ft impr egnated with Azlocillin an d Ceftazidime was inse rted betw een the proximal ascending aorta and the arch. Avein
False an eurysm of the ascending aorta can pr esent in many ways, including chest pain , dysphagia, stridor, a pulsatile suprastern al mass , or evidence of myocardi al ischaemia due to compression of coronary bypass grafts by the an eurysm (10). It usually occurs following mediastinal infection and has been reported as arising from the aortic cannulation site (2), particularly if foreign bodies such as felt pledgets ar e used in closure (1). Further cases have also been reported arising from needle puncture sites (3), and the aortic suture line (10). Aortic false an eurysms, and an eur ysms of the sinus of Valsalva , have been complicated by rupture into the right atrium with left-to-right shunt (7)or infective endocarditis. Cardio-cutaneous fistulae have been described following the use offelt pledgets in the resection of left-ventricular aneurysms (9). A case in which a false aneurysm following aorti c valve surgery has pr esent ed as an aorto-cutaneous fistula has not been previously docum ent ed. The diagnosis of aorto -cutaneous fistula was suggest ed by the dramatic nature of the history in both pati ents. Both CT scan and magnetic resonance imaging correctly dia gnosed and localised the false aneurysms. Computeris ed tomography is widely availabl e, and many units have extensive experience in its use and interpretation. Access to and experience with magnetic resonance imaging is less common . Transfer of sick patients to either imaging tool may be hazardous. The electromagnetic fields generated during magn etic resonance imagin g can hind er the safe monitoring of an unstable pati ent. However, the method is non -invasive, avoids the use of isonising radi ation and intr avenous contrast medium and gives better soft tissu e contrast resolution than CT(4). Echocardiography is another non -invasiv e technique which has been recommend ed to imag e this type ofl esion (6). The pr oblems of sur gical repair of false aneurysms after aor tic surg ery are severe uncontrolled ha emorrhage from the aneurysm during sternotomy or mobilisation of densely adh erent retr osternal tissu es (1) , damage to the right coronary artery dur ing retraction of th e sternum (2), and difficulty and bleeding during dissection around the aorta. Femoro-femor al car dio-pulmonary bypass with hypothermi c cardiac arrest has been utilised in the tr eatment of pr evious cases of false an eurysm of the aorta (8), and allows circulatory arrest to be used should severe bleeding occur whilst the chest is being opened. In the second case circulatory arrest was used to reimplant a prosthetic graft. Using this techniqu e both patients made a satisfactory recovery from a potentially lifethreatening complication of aortic surgery.
Downloaded by: NYU. Copyrighted material.
46
Thora c. car dio vasc. Su rgeon 40 (1992)
A orto-cutane ous Fis tula: A Ra re Comp lica tion ofAo rt ic S urge ry
1
2
3
4
5
6
Bojar, R. M.. D. D. Payn e. A. B. S heffield. H. Rast eqar, J. J. S tetz. a nd R. J. Cleveland: Successful repair of pos toperat ive as cending aortic mycotic false a ne urysms using circulatory a rrest. Ann. Thora c. Surg.46(1 988) 182-1 86 Branchini. B: B. Zingo ne. and M. Vaccari: Ascending aortic false aneurysm followin g cannulation for perfu sion. Thorax 31 (197 6) 234- 237 Eliot. R. 5.. M. J. Levy. C. W. Lillehei, and 1. E. Edwards: False a ne urysm of the asc end ing ao rta following need le pun cture an d cross clamping. J. Tho rac . Cardiovas c. Surg. 47 (196 4) 248- 253 Fischer. M. R.: Magnetic resonan ce for evalua tion of the thorax. Che st 95 (1989) 166- 173 Lillehei. C. w.. D. B. Todd. M. J. Levy. and R. J. Ellis: Partial ca rdiopulmonary bypas s. hypoth ermia. and total circulatory arrest. A life sa ving technique for rup tured left ventricle a nd other complicated ca rdiac pathology. J. Tho rac . Ca rdiovas c. Surg. 58 (1969) 530- 544 Mohan . J. c.. K. N. Reddy. S. K. Khanna. a nd M. Khalilu llah: Pseudoaneurysm of the ascending aorta complicating cardiac surger y: role of echocardiography in the diagnosis. lnt. J. Cardio!. 31 (1991 ) 33 -37
7
8
9
10
11
Photiou, S. A. . T. K. Kaul, an d J. L. Mercer: False ane urysm of th e ascendin g aort a with aortico-right atrial fistula . Thorax 36 (1981) 796-797 Pillai, R.. G. Venn. S. C. Lennox. and M. Paneth : Elective femorofemoral bypass for operations on th e hear t and grea t vess els. J . Thorac. Car diovasc . Surg. 88 (1984) 635 -63 7 S tanfo rd. Wo, C. F. Reuben. R. J. Flemma , D. C. Mullen. D. Lepley. and G. N. Olinger: Man agement of long-standing ca rdiocutaneo us fistulas after resection of left ventricular a neur ysms . J . Thora c. Cardiovas c. Surg. 79 (1980) 789-792 Sullivan. K. L.. R. M. Steiner. S. N. S mullens. L. Grisk a; and S. G. Meist er: Pseudoaneu rysm of th e ascending ao rta following ca rdiac surgery. Chest 93 (1988) 138-142 Winds or. H. M.. and M. X. S hanahan: Unusual a neury sms of the root of the aorta . J. Thorac. Cardiova sc. Sur g. 53 (1967) 83 1-836
Dr. B. Bridgewater 13 Beethoven St GB-London WI0 4LG Grea t Britain
Downloaded by: NYU. Copyrighted material.
Referen ces
47
Aorto-cutaneous Fistula: A Rare Complication ofAortic Surgery B. 1. M. Bridgewater, V Tsang, 1. Pepper, and S. C. Lennox Department ofCardiothoracicSurgery, Royal Brompton National Heart and LungHospitals Fulham Road, London, Great Britain
Two cases of false an eur ysm of the as cending aorta which pr esented with discharge of arter ial blood from a stern al wound ar e discuss ed. The first presented 8 years after aorti c valve surgery and was diagnos ed by contrast enhanced computerised tomograph y of the th orax . The seco nd pr esent ed 6 month s following repair of an aortic diss ection and the dia gnosis was confirmed by thoracic magnetic resonan ce imaging. The diagnosis and surgical man agement of th ese cases ar e reviewed . Keywo rds
Aorto-kutane Fistel: Eine seltene Komp likation der Aortenc hir urgie Es wird tiber zwei Faile eines falschen Aneurysmas der Aorta ascendens berichtet, die sich dur ch den Ausstrom von arteriellem Blut aus einer Sternumwunde bemerkbar ma chten . 1m ersten Fall tr at das Ere ignis 8 Jahre na ch einem Aortenklappe ners atz auf, die Diagn ose konnt e mit Hilfe eines Kontrast- CTs gestellt werden . 1m zweiten Fall wurde 6 Monate zuvor eine Aortendisse ktion korri giert, hier wur de die Diagnose anha nd eines NMR des Thorax best atigt, Die Diagnose un d das chiru rgische Vorgehe n in beiden Fallen wird erortert.
Aorto-cuta neo us fistula - Cardiac surgery - Computerised tomography - Magnetic resonan ce imaging
Introduction Fals e aneurysm of th e as cending aorta, a rare complication of cardiac surger y, has been reported as arising from th e aortic cannulation site (2), needle puncture sites, and the aortic suture line (11). The pr esentation of a false an eurysm as an aorto-cutaneous fistula has not been previously described. Two such cases pr esented to our institution between 1988 and 1990.
aortic suture line. The defect was closed with two interrupted suture s of 2/0 pr olen e, th e pati ent came ofT bypass well, th e sternum was debrid ed and all infected mat erial rem oved. She mad e a sa tisfactory haemodynam ic recovery but developed a left-sided weakn ess which resolved during her hospit al stay. She was dis charge d to convalesce nce 3 weeks after surgery.
Case Rep orts Case I : A 78-year-old lad y, who had had an aortic valve replacement 10 years pr eviously, had a three year hist ory of chronic discha rge from sinuses in her stern al wound. She pr esent ed with a brisk discharge of fresh blood through a sinus . An aorto-cutaneo us fistula was suspected. Computeris ed tom ography of the th orax showed an extensive density conta ining some calcification to the left sid e of th e asce nding aorta, just sup erior to th e aortic root (Fig. 1). This lesion enhanced following administration of intravenous contrast suggesting an an eurysm (Fig. 2). At operation, a technique was employed to ena ble circulatory arrest to be used should severe bleeding occur (5). Femora-femoral bypass was esta blishe d and th e patient was cooled . When the core temperatur e reached 30 °C the sternum was care fully opened whilst th e temp erature was allowed to go lower. When it becam e appa re nt that circulat ory arrest was not necessary. she was rewarmed to 28 °C. A small, well-dema rcate d bleedin g point wa s pr esent in a false ane urysm at the pulmonary artery end of th e
Thorac. cardiovasc. Surgeon 40 (1992) 45-47 © Georg Thieme Verlag Stuttgart · New York
Fig. 1 Case 1. CTscanof thethoraxdemonstrates anextensivedensityonthe left side of the ascending aorta,just superior to theaortic root
Received for Publication: Septe mber 2, 199 1
Downloaded by: NYU. Copyrighted material.
Summary
Thom e. eardiovase . Surgeon 40 (1992)
B. 1. M. Bridgewater. V. Tsang. J. Pepp er. and S. C. Lennox
gra ft from the long saphenous vein was anas tomosed between the distal right coronary artery and the anterior asp ect of th e Dacr on graft. The grea ter omentum was mobilised and inserted into the chest anterior to the graft. Postoper atively he developed a sever e wound infection which requir ed fur ther surgical debridem ent and the placement of a free left latissimus dorsi muscle flap . He mad e a slow but satisfactory recovery and was discharg ed to home six weeks following his admission. He was alive and well when we last saw him .
Discussion
Fig.2 Case 1.The lesion shownin Fig. 1 has enhanced followingintra-venous injection of contrast
Fig. 3 Case 2. Magnetic resonance imagingof thethorax shows theaortic archto bedilated,withafalselumen containingclotted blood.Thereisalsoan extensive soft tissue mass lying anteriorlyto the ascendingaorta
Case 2: A 60-year -old man was transferred to our hospital 6 month s following an aortic dissection for which he had had a Dacron gra ft insert ed into his asce nding aorta . Postoperatively he had developed a severe stern al wound infection which required exte nsive surgery to excise his sternum and mobilise muscle flaps from both pectorals and the right rectus shea th. He mad e a good recovery from this initial opera tion. Sever al days pri or to his tr an sfer to us he had episodes of bright red blood bleedin g from a sinus at the lower end of his sternal wound. An aorto-cuta neous fistula was again suspec ted. Magnetic resonan ce imaging of the thorax sh owed the aortic arch to be dilated, with a false lumen contai ning blood clot. There was an extensive soft tissue mass lying anterio rly to the asce nding aor ta (Fig. 3). A coronary arteriogra m revealed a 70 % stenos is of the right corona ry arte ry. A similar surgical techniqu e to the previous case was used. Femoro-fem oral bypass was estab lished and the patient was slowly cooled. The anterior ches t wall was opened in the midline. Ther e was a lar ge amount of infected material assoc iated with a false ane urys m on th e anter ior aspect of the aorta. The patient was cooled to 18 °C and the circulation was arres ted . The infected Dacron gra ft was re moved along with all othe r infected material. A 'Gelsea l' Dacron gra ft impr egnated with Azlocillin an d Ceftazidime was inse rted betw een the proximal ascending aorta and the arch. Avein
False an eurysm of the ascending aorta can pr esent in many ways, including chest pain , dysphagia, stridor, a pulsatile suprastern al mass , or evidence of myocardi al ischaemia due to compression of coronary bypass grafts by the an eurysm (10). It usually occurs following mediastinal infection and has been reported as arising from the aortic cannulation site (2), particularly if foreign bodies such as felt pledgets ar e used in closure (1). Further cases have also been reported arising from needle puncture sites (3), and the aortic suture line (10). Aortic false an eurysms, and an eur ysms of the sinus of Valsalva , have been complicated by rupture into the right atrium with left-to-right shunt (7)or infective endocarditis. Cardio-cutaneous fistulae have been described following the use offelt pledgets in the resection of left-ventricular aneurysms (9). A case in which a false aneurysm following aorti c valve surgery has pr esent ed as an aorto-cutaneous fistula has not been previously docum ent ed. The diagnosis of aorto -cutaneous fistula was suggest ed by the dramatic nature of the history in both pati ents. Both CT scan and magnetic resonance imaging correctly dia gnosed and localised the false aneurysms. Computeris ed tomography is widely availabl e, and many units have extensive experience in its use and interpretation. Access to and experience with magnetic resonance imaging is less common . Transfer of sick patients to either imaging tool may be hazardous. The electromagnetic fields generated during magn etic resonance imagin g can hind er the safe monitoring of an unstable pati ent. However, the method is non -invasive, avoids the use of isonising radi ation and intr avenous contrast medium and gives better soft tissu e contrast resolution than CT(4). Echocardiography is another non -invasiv e technique which has been recommend ed to imag e this type ofl esion (6). The pr oblems of sur gical repair of false aneurysms after aor tic surg ery are severe uncontrolled ha emorrhage from the aneurysm during sternotomy or mobilisation of densely adh erent retr osternal tissu es (1) , damage to the right coronary artery dur ing retraction of th e sternum (2), and difficulty and bleeding during dissection around the aorta. Femoro-femor al car dio-pulmonary bypass with hypothermi c cardiac arrest has been utilised in the tr eatment of pr evious cases of false an eurysm of the aorta (8), and allows circulatory arrest to be used should severe bleeding occur whilst the chest is being opened. In the second case circulatory arrest was used to reimplant a prosthetic graft. Using this techniqu e both patients made a satisfactory recovery from a potentially lifethreatening complication of aortic surgery.
Downloaded by: NYU. Copyrighted material.
46
Thora c. car dio vasc. Su rgeon 40 (1992)
A orto-cutane ous Fis tula: A Ra re Comp lica tion ofAo rt ic S urge ry
1
2
3
4
5
6
Bojar, R. M.. D. D. Payn e. A. B. S heffield. H. Rast eqar, J. J. S tetz. a nd R. J. Cleveland: Successful repair of pos toperat ive as cending aortic mycotic false a ne urysms using circulatory a rrest. Ann. Thora c. Surg.46(1 988) 182-1 86 Branchini. B: B. Zingo ne. and M. Vaccari: Ascending aortic false aneurysm followin g cannulation for perfu sion. Thorax 31 (197 6) 234- 237 Eliot. R. 5.. M. J. Levy. C. W. Lillehei, and 1. E. Edwards: False a ne urysm of the asc end ing ao rta following need le pun cture an d cross clamping. J. Tho rac . Cardiovas c. Surg. 47 (196 4) 248- 253 Fischer. M. R.: Magnetic resonan ce for evalua tion of the thorax. Che st 95 (1989) 166- 173 Lillehei. C. w.. D. B. Todd. M. J. Levy. and R. J. Ellis: Partial ca rdiopulmonary bypas s. hypoth ermia. and total circulatory arrest. A life sa ving technique for rup tured left ventricle a nd other complicated ca rdiac pathology. J. Tho rac . Ca rdiovas c. Surg. 58 (1969) 530- 544 Mohan . J. c.. K. N. Reddy. S. K. Khanna. a nd M. Khalilu llah: Pseudoaneurysm of the ascending aorta complicating cardiac surger y: role of echocardiography in the diagnosis. lnt. J. Cardio!. 31 (1991 ) 33 -37
7
8
9
10
11
Photiou, S. A. . T. K. Kaul, an d J. L. Mercer: False ane urysm of th e ascendin g aort a with aortico-right atrial fistula . Thorax 36 (1981) 796-797 Pillai, R.. G. Venn. S. C. Lennox. and M. Paneth : Elective femorofemoral bypass for operations on th e hear t and grea t vess els. J . Thorac. Car diovasc . Surg. 88 (1984) 635 -63 7 S tanfo rd. Wo, C. F. Reuben. R. J. Flemma , D. C. Mullen. D. Lepley. and G. N. Olinger: Man agement of long-standing ca rdiocutaneo us fistulas after resection of left ventricular a neur ysms . J . Thora c. Cardiovas c. Surg. 79 (1980) 789-792 Sullivan. K. L.. R. M. Steiner. S. N. S mullens. L. Grisk a; and S. G. Meist er: Pseudoaneu rysm of th e ascending ao rta following ca rdiac surgery. Chest 93 (1988) 138-142 Winds or. H. M.. and M. X. S hanahan: Unusual a neury sms of the root of the aorta . J. Thorac. Cardiova sc. Sur g. 53 (1967) 83 1-836
Dr. B. Bridgewater 13 Beethoven St GB-London WI0 4LG Grea t Britain
Downloaded by: NYU. Copyrighted material.
Referen ces
47
