Chronic, Traumatic Pseudoaneurysm of the Ascending Aorta Felipe C. Albuquerque, BA, Mark J. Krasna, MD, and Joseph S. McLaughlin, MD Division of Thoracic and Cardiovascular Surgery, University of Maryland School of Medicine, Baltimore, Maryland

Rupture of the ascending aorta is lethal in virtually all cases. In the recent literature, fewer than 9 cases of chronic, traumatic pseudoaneurysm of the ascending aorta have been documented. Reported herein is such a case, discovered incidentally and repaired successfully under cardiopulmonary bypass using a graft prosthesis. Aortogram remains the diagnostic method of choice in these patients. (Ann Thorac Surg 1992;54:980-2)

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upture of the aorta usually occurs after deceleration injury sustained in motor vehicle accidents. Less than 20% of people with this injury survive the event. Two percent of those suffering rupture at the level of the isthmus go on to have development of a chronic aneurysm [l]. Rupture at the level of the aortic root is virtually uniformly fatal secondary to instantaneous cardiac tamponade and other associated cardiac injuries [2]. Reported is a case of pseudoaneurysm of the ascending aorta successfully repaired using cardiopulmonary bypass. A 34-year-old man suffered a gunshot wound to the left precordium on January 12, 1991, after which he underwent emergent median sternotomy (at another hospital) for relief of acute pericardial tamponade. The bullet, located within the myocardium of the right ventricle, was not removed because the operating room was not equipped for cardiopulmonary bypass. At that time, a large, stable aneurysm of the ascending aorta was noted. Computed tomographic scan 2 days postoperatively showed an aneurysm of the ascending aorta arising above the level of the aortic valve (Fig 1). A sagittal magnetic resonance image revealed bilateral pleural effusions. Transfemoral aortogram demonstrated a secular aneurysm approximately 7 cm x 9 cm originating 2 cm above the coronary ostia (Figs 2, 3). Upon admission to University of Maryland, the patient reported a medical history significant for three motor vehicle accidents (1979, 1980, and 1990), during which the patient suffered fractures of several ribs and a right pneumothorax. The patient denied a history of sexually transmitted disease (including syphilis), hypertension, or familial illnesses. Accepted for publication Feb 12, 1992. Address reprint requests to Dr Krasna, Division of Thoracic and Cardiovascular Surgery, University of Maryland Hospital, 22 S. Greene St, Baltimore, MD 21201.

0 1992 by The

Society of Thoracic Surgeons

The physical examination and laboratory tests were within normal limits. An electrocardiogram showed normal sinus rhythm with an incomplete right bundle-branch block. A chest roentgenogram showed a slightly widened mediastinum, a normal cardiac silhouette, a bullet near the apex of the heart, and normal lung fields. On February 8, 1991, a median sternotomy was performed through the previous incision, which revealed a 7 cm x 7 cm aneurysm, 2 cm above the aortic valve. After the patient was placed on femoral cardiopulmonary bypass and the left ventricle was decompressed, the aorta was cross-clamped and retrograde cardioplegia injected. The aneurysm was entered, demonstrating a false lumen arising from the aorta 3 cm above the coronary ostia. The aneurysm was resected and a 24-mm Dacron graft, previously autoclaved in plasma, was selected to bridge the site. The proximal anastomosis was performed first using 2-0 Ethibond (Ethicon, Somerville, NJ) pledgeted, interrupted mattress sutures. The distal anastomosis was completed by running 3-0 Prolene (Ethicon) sutures buttressed by Teflon strips. At this point, the apex of the heart was elevated and the bullet removed. The patient was weaned off bypass without complication. He did well after operation and was discharged on postoperative day 7.

Comment Deceleration injuries are likely to occur at the level of the ligamentum arteriosum, where the relatively mobile heart and arch join the fixed descending aorta. Nevertheless, displacement of the heart into the left posterior chest can subject the ascending aorta to torsion, accounting for the relative frequency of rupture in this area. The likelihood of concomitant valvular and cardiac damage with ascending aortic rupture, however, makes it far less likely that a patient will survive the initial traumatic event and go on to have development of a chronic pseudoaneurysm [3]. Indeed, in their review of the literature spanning 1950 to 1980, Finkelmeier and associates [2] report fewer than 9 cases (3%of a total of 284) of chronic, traumatic aneurysm arising above the aortic valve [2]. Recently, dissections occurring after cardiac operations have become the leading cause of ascending aortic dissection. In the case reported herein, both the histology and the history confirm the presence of a chronic pseudoaneurysm. A chronic aneurysm is defined as one that persists longer than 3 months after the original traumatic event. Such is the case for this patient, whose most recent motor vehicle accident preceded the diagnosis of his aneurysm 0003-4975/92/$5.00

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CASE REPORT ALBUQUERQUE ET AL PSEUDOANEURYSM OF AORTA

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Fig 1 . Computed tomographic scan of the chest showing bilateral pleural effusions (black arrow) and enlarged ascending aorta (white arrow).

by 5 months. Pseudoaneurysms, unlike true aneurysm, are contained only within a thin layer of adventitia and not by the natural sequelae of such lesions [4]. Pathologic examination of our patient’s aorta revealed a false, saccular pouch consisting only of fibrous tissue. Considering the lethality of rupture, early diagnosis of an aortic aneurysm is imperative. Symptoms associated with enlarging aneurysms include pain, dyspnea, cough, and hoarseness. Without these symptoms, the presence of a widened mediastinum on chest roentgenogram is the initial diagnostic clue. The definitive diagnosis is made,

Fig 3. Lateral aortogram showing aneurysm (upper arrow) and bullet (lower arrow).

however, through the use of aortography, which will delineate not only the aneurysmal site but the anatomy of adjacent sections of the aorta as well. The latter is especially critical in cases involving the aortic arch and bifurcation. Other methods of diagnosis include the use of Doppler echocardiography and computed tomography [5, 61. The primary advantage of these modes is their noninvasiveness, which may be of importance when assessing the acutely traumatized patient. Based on their proclivity to rupture even several years after development, traumatic pseudoaneurysms of the aorta are treated with excision and prosthetic repair [ 7 ] .In 1956, Cooley and De Bakey [8] became the first to repair a chronic, traumatic pseudoaneurysm of the ascending aorta. Their work, as well as the successful outcome of the patient described herein, confirms that chronic aneurysms of the ascending aorta can be managed safely through operative intervention. Given the few cases of chronic, posttraumatic aneurysms of the ascending aorta, it is difficult to quantitate the risk of death from operation versus that of delayed rupture. Nevertheless, data on patients with chronic aneurysms of the descending aorta suggest that the mortality rate is far less for surgical repair than for delayed rupture (4.6% versus 33%, respectively) [ 2 ] .

References Fig 2. Anteroposterior aortogram demonstrating large ascending aortic pseudoaneurysm medial to the left edge of the ascending aorta (ar-

row).

1. Parmley LF, Mattingly TW, Manion WC, Jahnke EF. Nonpenetrating traumatic injury of the aorta. Circulation 1958;17: 1086-101.

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Finkelmeier BA, Mentzer RM, Kaiser DL, Tegtmeyer CJ, Nolan SP. Chronic traumatic thoracic aneurysm: influence of operative treatment on natural history. An analysis of reported cases, 1950-1980. J Thorac Cardiovasc Surg 1983;M: 257-66. Schwartz ML, Fisher R, Sako Y, Castaneda AR, Grage TB, Nicoloff DM. Post-traumatic aneurysms of the thoracic aorta. Surgery 1975;78:589-93. Bennett DE, Cherry JK. The natural history of traumatic aneurysms of the aorta. Surgery 1967;61:516-23. Moya JL, de Pablo C, Sanchez M, Bamos V, Fraj J, Asin-

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CardieI E. Traumatic rupture of aorta: diagnosis by Doppler echocardiography. Chest 1990;98:1016-7. White RD, Lipton MJ, Higgins CB, et al. Noninvasive evaluation of suspected thoracic aortic disease by contrastenhanced computed tomography. Am J Cardiol 1986;57 282-90. Cooley DA. Aneurysms of the ascending aorta: surgical treatment using hypothermic arrest. Cardiology 1990;7737M37. Cooley DA, De Bakey ME. Resection of entire ascending aorta in fusiform aneurysm using cardiac bypass. JAMA 1956;162: 1158-9.

Notice From the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the operations they performed during the year prior to application for recertification. This practice review should consist of 1 year’s consecutive major operative experiences. (If more than 100 cases occur in 1 year, only 100 need to be listed.) They should also keep a record of their attendance at approved postgraduate medical education activities for the 2 years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS IV syllabus (Self-Education/Self-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase

SESATS IV booklets prior to applying for recertification. SESATS IV booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1995 may begin the recertification process in 1993. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is May 1, 1993. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.

Chronic, traumatic pseudoaneurysm of the ascending aorta.

Rupture of the ascending aorta is lethal in virtually all cases. In the recent literature, fewer than 9 cases of chronic, traumatic pseudoaneurysm of ...
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