Pancreatitis-related abdominal aortic pseudoaneurysms treated with stent-grafts

Endovascular treatment of pseudoaneurysms that develop as a complication of pancreatitis is increasingly more common. A case of a pseudoaneurysm of the abdominal aorta initially treated by implantation of a straight aortic stent-graft is presented. In the 4 months after the procedure, chronic inflammation of the retroperitoneal space caused a further perforation on the posterior wall of the aorta in the area of the bifurcation, distal to the graft. Implantation of a bifurcated stent-graft was subsequently performed. The aneurysm was excluded, with the implant and peripheral arteries remaining patent.     

Perforation of the aorta by a rib edge: an unusual complication after chest wall resection

Thoracic aortic perforation in the context of a minor trauma is extremely rare. In this article, we describe a case of an 80-year-old man who presented with an aortic perforation after a fall from his height during his hospitalization. The patient had previously undergone a left superior lobectomy, a partial chest wall resection, and reconstruction for a locally invasive lung cancer. He was directly transferred to the operating room, as he presented with hemodynamic instability. A 4-mm laceration in the descending thoracic aorta was identified and repaired. The postoperative course was uneventful. This case illustrates the importance of applying a solid fixation to the rib stumps when performing a chest wall resection, irrespective of the size of the wall defect.     

An aneurysm at the cannulation site discovered 40 years after cardiac surgery: report of a case

We report the successful surgical treatment of a pseudoaneurysm of the ascending aorta in a 45-year-old man who underwent surgical closure of a ventricular septal defect at the age of 5. A computed tomography scan ordered for the investigation of a pulmonary mass happened to detect a pseudoaneurysm (20 mm diameter). The pseudoaneurysm protruded anteriorly from the ascending aorta at the previous aortic cannulation site. The ascending aorta, including the lesion, was replaced with a prosthetic graft uneventfully. The cause of the pseudoaneurysm was considered iatrogenic, since he had no prior history of postoperative mediastinitis or blunt chest trauma. A computed tomography scan is a useful means to detect a mass on the ascending aorta following cardiac surgery, and it provides important information to help define a surgical strategy.     

Late pseudoaneurysm formation after patch angioplasty of coarctation of the aorta; report of a case

We report a case of a 13-year-old boy presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair a coarctation of the aorta. At the age of 3 months, he had undergone patch angioplasty for a coarctation of the aorta, which develops following patent ductus arteriosus division at 2 months of age. He was treated by distal aortic arch replacement using 16 mm woven Dacron tube graft in an end-to-end fashion with open proximal anastomosis under deep hypothermic circulatory arrest. The aneurysm was in the aortic wall opposite the patch graft. There was no evidence of infection or dilatation of the patch graft. This case illustrates that repair of aortic coarctations with Dacron patches cannot be recommended.     

Aortobiventricular fistulas associated with pseudoaneurysm of the ascending aorta 12 years after patch repair of supravalvular aortic stenosis

Fistula formation between the aorta and cardiac chamber is a rare complication of the ascending aortic aneurysm. A 27 year-old man undergoing successful patch aortoplasty for supravalvular aortic stenosis 12 years before admission had a high fever, infectious signs in blood laboratory data, and congestive heart failure. Transthoracic and transesophageal echocardiography revealed a pseudoaneurysm of the aortic root and aortobiventricular fistulas. Detachment of the proximal end of the aortic patch was thought to be the cause of the pseudoaneurysm. Debridement of necrotic tissue surrounding fistulas produced large defects in the anterior wall of the right ventricle, interventricular septum, and ascending aorta. A modified Konno operation effectively reconstructed the outflow tracts of both ventricles and the aorta.     

Descending Aortic Dissection Originating from a Juxtaductal Traumatic Aneurysm: Technical Considerations

A 65-year-old male presented with a descending aortic dissection. His past history was remarkable for severe blunt chest trauma 26 years prior to presentation. Operative and pathologic findings included a posttraumatic pseudoaneurysm of the thoracic aorta and an aortic dissection that originated from the orifice of the pseudoaneurysm. The ductal fovea, the mouth of the pseudoaneurysm, is an area that may be more susceptible to accelerated atherosclerosis and the complications of atherosclerosis including aortic dissection. (J Card SUrg 1994;9:65–69)     

Endovascular treatment of an abdominal aortic pseudoaneurysm as a late complication of inferior vena cava filter placement

Pseudoaneurysms of abdominal aorta after inferior vena cava (IVC) filter placement are uncommon, with associated morbidity and mortality. We report a case in which an abdominal aortic pseudoaneurysm resulted from erosion of a Bird's Nest (Cook, Bloomington, IN) IVC filter into the wall of the abdominal aorta. A 64-year-old woman with an IVC filter placed 10 years prior presented to the emergency department complaining of abdominal pain. A computed tomography scan of the abdomen and pelvis showed a 1.4-cm x 2.0-cm infrarenal aortic pseudoaneurysm adjacent to the IVC filter site. A Zenith endograft (Cook) was used via an open femoral artery exposure to successfully treat the pseudoaneurysm.     

Bronchogenic cyst masquerading as a chronic post-traumatic pseudoaneurysm of the aortic isthmus.

The serious nature of false aneurysms that develop in the aortic isthmus after blunt chest trauma is well known. The authors describe the case of a 33-year-old woman who presented with symptoms of chronic post-traumatic pseudoaneurysm of the aorta 3 months after blunt chest trauma. Radiologic investigations could not substantiate an aortic disruption. A bronchogenic cyst masquerading as a false aneurysm of the aorta was identified at thoracotomy. Bronchogenic cysts are one of the most common causes of primary mid-mediastinal masses and should be considered as potential causes of mid-mediastinal enlargement. However, this consideration should not delay urgent surgery if vascular damage cannot be ruled out.     

Spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm.

We report on the rare and successful surgical treatment of a case of spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm. A 72-year-old male who had complained of sudden onset of severe chest pain was admitted to our hospital. Initially, acute type A closing aortic dissection was suspected because computed tomography (CT) showed a small ulcer-like projection (ULP) in the posterior aspect of the ascending aortic wall, but it also revealed no intimal flap, false lumen or aortic aneurysm. CT and magnetic resonance imaging (MRI) indicated a change in the radiographic aspect of the ULP and revealed a mimicking saccular-type pseudoaneurysm and gradual increasing size of the pseudoaneurysm. Surgery was performed after considering the risk of pseudoaneurysmal rupture. We replaced the ascending aorta and diagnosed it as a spontaneous aortic rupture by histological examination of the rupture site after failing to observe an aneurysm or dissection. We discuss these results with reference to the literature, including our pathological and radiographical findings.     

Endovascular repair of a presumed aortoduodenal fistula.

This report describes the use of transluminal endovascular grafting for the treatment of a presumed aortoduodenal fistula. The patient was a 71-year-old man who had undergone resection and graft replacement for an abdominal aortic aneurysm. Three years after operation, melena was caused by perforation of the duodenal wall by a pseudoaneurysm at the proximal graft anastomosis. The pseudoaneurysm was treated by transluminal endovascular grafting. The pseudoaneurysm was subsequently thrombosed and absorbed. The ulcer-like lesions at the site of the duodenal wall perforated by the pseudoaneurysm also resolved. Endovascular stent-grafts may have a role to play in management of aortoduodenal fistula.     

Rapidly progressive descending aortic pseudoaneurysm resulting from primary malignant fibrous histiocytoma

A 66-year-old man with a history of asymptomatic bilateral swelling of the axillary lymph nodes was admitted with hoarseness and pain of the right knee. Computed tomography showed a large pseudoaneurysm deriving from descending aorta. We planned to resect the pseudoaneurysm, and repair the aortic wall. Resection of the pseudoaneurysm and patch-closure of the defect of the aorta were performed successfully. Pathological examination of the pseudoaneurysm revealed malignant fibrous histiocytoma. The clinical course was very miserable. Intrathoracic recurrence occurred 7?months after surgery, and he died of multiple brain metastases 10?months postoperatively.     

A combination of reoperation for pseudoaneurysm following the Cabrol procedure and total aortic arch replacement in a patient with Marfan syndrome —A case with an aberrant right subclavian artery—

A 44-year-old male with Marfan’s syndrome had undergone an initial operation for DeBakey type I acute aortic dissection with annulo-aortic ectasia. He had undergone replacement of the ascending aorta and aortic valve with a composite graft and reconstruction of the coronary artery by the Cabrol procedure. At 5 years after the initial surgery he experienced chest pain and was subsequently examined. Computed tomography revealed a pseudoaneurysm in the ascending aorta and the residual aortic dissection. The maximum diameter of the pseudoaneurysm was 85 mm and the maximum diameter of the aortic arch was 55 mm. The aortic arch was associated with an aberrant right subclavian artery. Angiography revealed that the pseudoaneurysm was caused by leakage at the coronary ostium-graft anastomoses. We repaired the anastomoses and performed total aortic arch replacement with reconstruction of four arch branches. The postoperative course was uneventful without any complications. We report this case because there have been few reports regarding arch replacement in cases with an aberrant right subclavian artery.     

Treatment Options for Traumatic Pseudoaneurysms of the Paravisceral Abdominal Aorta

Penetrating gunshot wounds (GSWs) to the abdominal aorta are frequently lethal. Alternative management options for treatment of traumatic pseudoaneurysms of the abdominal aorta are illustrated by three patient case histories. Patient A sustained two GSWs to the abdomen (midepigastrium, right subcostal region). He was hypotensive in the field. Emergent laparotomy was undertaken with suture ligature of a celiac injury and distal pancreatectomy/splenectomy for a pancreatic injury. Postoperative abdominal CT for an intraabdominal infection with leukocytosis revealed a 4 cm traumatic pseudoaneurysm of the abdominal aorta that extended from the suprarenal aorta to the level of the renal arteries. Six weeks later, he underwent an open repair. Patient B sustained multiple GSWs to his right arm and right upper quadrant. He was hemodynamically stable. He underwent abdominal exploration for a grade 3 liver laceration. Postoperative abdominal CT revealed a supraceliac abdominal aortic pseudoaneurysm. An aortogram demonstrated a 1.5 cm defect in the aortic wall above the celiac trunk communicating with the inferior vena cava (IVC). He underwent endovascular repair with covered aortic stent graft. Patient C sustained multiple thoracoabdominal GSWs. He was hemodynamically stable. Emergent laparotomy revealed multiple left colonic perforations, two duodenal lacerations, and an unsalvageable left kidney laceration. Postoperatively, he developed a duodenal-cutaneous fistula with multiple intraabdominal abscesses. Serial CT scans revealed an enlarging infrarenal aortic pseudoaneurysm. He underwent angiographic coil embolization and intraarterial injection of thrombin into the pseudoaneurysm sac. The average time from injury to surgical treatment was 46 days (range 29-67). Postoperatively, none of the patients developed paraplegia. Advances in endovascular techniques have provided options to deal with traumatic pseudoaneurysms of the abdominal aorta. In a hemodynamically stable patient with a traumatic pseudoaneurysm, careful selection of a specific intervention can be tailored to the clinical scenario electively.Presented at the 22nd Annual Meeting of the Southern California Vascular Surgery Society, La Jolla, CA, April 30-May 2, 2004.     

The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report

Introduction and importancePenetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up.Case presentationA 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day.Clinical discussionEmergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury.ConclusionThis case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection.     

Endovascular approach to treat aortic pseudoaneurysms: could it be a safe alternative?

Aortic pseudoaneurysm is a rare complication after blunt chest trauma or cardiac surgical procedures and can occur at the site of cannulation or root vent insertion on the ascending aorta. These pseudoaneurysms have the potential to expand, erode, and rupture, and detecting this condition before complications occur is the key to successful management. We had replaced the mitral valve with a 31-mm bioprosthesis in an 82-year-old patient and repaired an ascending aorta aneurysm, but a computed tomography scan on postoperative day 18 revealed a pseudoaneurysm at the site of the previous aortic cannulation. Because of the patient's advanced age and multiple comorbidities, we sealed off the neck of the pseudoaneurysm with a 12-mm Amplatzer Vascular Plug in the interventional cardiology suite instead of subjecting her to a surgical repair involving redo sternotomy and a period of circulatory arrest. Deployment of the Amplatzer plug effectively shut off flow into the pseudoaneurysm, and the patient recovered well. Although the optimal management strategy for aortic pseudoaneurysms is a matter of controversy, endovascular interventions may be a safer alternative to surgery for patients with multiple comorbidities.     

Pseudoaneurysm of the abdominal aorta following blunt trauma

Pseudoaneurysm of the abdominal aorta may occur as a consequence of blunt abdominal trauma. Immediate surgery should be performed, once the diagnosis of aortic disruption is made because it is potentially lethal injury. We present a case of a young man, who underwent successful surgical treatment of abdominal aortic pseudoaneurysm following blunt trauma.     

Ischemic esophageal necrosis secondary to traumatic aortic transection

Esophageal necrosis with perforation secondary to traumatic aortic transection is extremely rare but usually fatal. A 47-year-old man complained of sudden swallowing difficulty 6 days after blunt trauma. Computed tomography showed a ruptured aorta and the midesophagus shifted to the right side with luminal obliteration because of the ruptured aorta. After primary repair of the partially transected aorta, unexpected mediastinitis because of esophageal perforation was noted. Upper endoscopy showed midesophageal ulceration, necrosis, and perforation. Biopsy samples were consistent with ischemia. The possibility of direct esophageal trauma or intraoperative esophageal injury was ruled out. Esophageal exclusion with thoracoscopic decortication and multiple antibiotics were ineffective, and the patient eventually died. Ischemic esophageal necrosis caused by mechanical compression can occur in a traumatic aortic transection. Dysphagia, when present with radiologic signs, indicates a displaced and compressed esophagus. In spite of aggressive surgical and medical treatment for a perforated esophagus, the prognosis remains poor.     

Mycotic pseudoaneurysm of the ascending aorta after heart transplantation: case report

Mycotic pseudoaneurysm of the ascending aorta is a rare but potentially life-threatening complication after orthotopic heart transplantation. We present a case of a 53-year-old man who developed a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation. The pseudoaneurysm was surgically resected and the ascending aorta was replaced with allograft. The Gram stain and multiple cultures of the pseudoaneurysm wall revealed that the causative microorganism was coagulase-negative Staphylococcus. To the best of our knowledge, this is the first case report that describes mycotic pseudoaneurysm owing to coagulase-negative Staphylococcus infection after heart transplantation. Although S aureus and Pseudomonas aeruginosa are common pathogens in previously published literatures describing mycotic pseudoaneurysms in heart transplant recipients, coagulase-negative Staphylococcus is aslo an important and virulent pathogen that can cause mycotic aortic pseudoaneurysm in immunosuppressed patients. Once diagnosed, aggressive surgical treatment with prudent operative strategy, appropriate postoperative antibiotic therapy and close follow-up by radiographic study are mandatory in managing patients with this potentially fatal condition.     

Successful management of pseudoaneurysm of the aorta complicating total correction in Tetralogy of Fallot

Pseudoaneurysm of the aorta is a dreaded complication which may develop after cardiac surgery requiring cardiopulmonary bypass. The pseudoaneurysm is described as an abnormal aneurismal dilatation arising from a weakened region of the aorta. The wall was composed of adventitia, portions of the media, and stretched and compressed surrounding anatomic structures. We are reporting successful management of a case of pseudoaneurysm of the aortic cannulation site.     

Aorto-Right Atrium Fistula Caused by Detachment After Bentall's Operation: Report of a Case

A 70-year-old woman was admitted to our hospital for treatment of right heart failure 16 years after undergoing Bentall's operation with a Cabrol shunt procedure. Various investigations showed detachment of the coronary artery and graft. We surmised that the heart failure was caused by a massive left to right shunt between a pseudoaneurysm of the wrapping aortic wall and the right atrium. Intraoperatively, we found a small fistula between the wrapping aortic wall and the right atrium, with complete closure of Cabrol shunt. We performed regrafting of the ascending aorta and reconstruction of the coronary ostium under cardiopulmonary bypass. The patient had an uneventful postoperative course. Detachment of the coronary ostium is a common long-term complication of Bentall's operation, but a Cabrol shunt between the wrapping aortic wall and the right atrium rarely causes congestive heart failure. A fistula between a pseudoaneurysm and the right atrium is even more unusual.