A novel treatment for Diffused Aorta Aneurysm: A Case
Report1
Xiaochen Wu1,2,Jinbao Zhang1,*, Hui Ouyang1, Feng Gao1, Qin Yue1
1 Division of Cardiothoracic Surgery, Military General Hospital, Chengdu, China, 610083
Abstract: Herein, we report a case of 27-year-old woman diagnosed of aorta true aneurysm caused by
aortitis. Despite the protopathic desease, the risk of aneurysm rupture, and she was referred to our
hospital to undergo surgery. Preoperative evaluations revealed an effective and fluent vascular
prosthesis-bypass from the ascending aorta to the thoracoabdominal aorta. A bypass-surgery was
carried out via median sternotomy and postoperative digital subtraction angiography showed excellent
reconstruction of the entire aorta and considerable trauma-releasing and smooth- rehabilitation
referring to tradition operations.
Key Words: aortitis, aortic aneurysm, bypass surgery
Introduction
Diffused aorta aneurysm is well known to affect various lesions such as the coronary artery, aortic
arch vessels, ascending aorta, and aortic valve [1]. Surgical treatment of this disease is difficult and a
high mortality and morbidity rate may be anticipated,because of the severity of the lesions and the
necessity to manipulate fragile tissue. Furthermore, the tradition-operations, like anatomic repair and
extra-anatomic bypass grafting, take patient great operation-injury. We performed successful
ascending-to-descending aorta bypass followed by ligation of the descending thoracic aortic aneurysm
through a combination of a median sternotomy and lateral incision in such a patient. We think that this
operation, which is used for complex descending thoracic aortic lesions such as recoarctation, is
another useful option for a diffuse thoracic aortic aneurysm. Thus, we report this case and discuss the
merits and demerits of this operation in comparison with other options.
Case Report
*Corresponding author: Department of Cardiothoracic Surgery,Chengdu Military General Hospital,Chengdu,
Si’chuan, 610083,China.
2First
Tel.: +86-28-86571263; fax: +86-28-86571263
author: Department of Cardiothoracic Surgery,Chengdu Military General Hospital,Chengdu, Si’chuan,
610083,China.
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E-mail:zhangjb1@126.com,
E-mail:nowwilson@yeah.net,
Tel.: +86-28-86571263; fax: +86-28-86571263
A 27-year-old man was admitted to our hospital for three-year-investigation of chronic
precordium pain without accompaniment of hoarseness, and dyspnea. The pain of precordium has
always being in costo- interspace on left mid-clavicular line. She was then given the final diagnosis of
a diffuse aortic aneurysm extending from the the banch of left-common carotid artery down to the
distal descending thoracic aorta in local hospital. Although her latest follow-up revealed that the
affected aorta distorted like a loop, the patient did not undergo surgical treatment because of little
experience of dealing with this kind of case. Computed tomography (CT) showed a loop-distorted
aneurysm stuffing in mediastinum (red arrow in Fig.1), and the tunica adventitia of aorta looked too
fragile to operate on. Because of those characterstics, we decided to do a palliation-operation through a
median sternotomy and lateral incision without blocking aorta. Thus, we performed median sternotomy
first, followed by ligation of left subclavian artery with slender dacron patch, and finally, a vascular
prosthesis with diameter of 2.5cm was anastomosed with aort arch and descending aorta respectively.
After completely and elaboratively hematischesis, thoracic cavity was shunt.Then the body position
was turn to right arm reclining.A lateral incision was made through the third lib-interspace, ligation
was then made at aortic isthmus with a Dacron strip. The cardiopulmonary bypass time was 67 min,
and the total operation time was 2h 10 min. The patient underwent extubatation on postoperative day 2,
and was discharged from the intensive care unit on postoperative day 5. No neurological and
cardiovascular complication was emerged except chylous hydrothorax.
She was finally discharged home 15 days after surgery. And postoperative steroid therapy was
recommended for one year[2]. Postoperative CT 5 years later showed uncomplete obstruction of the
excluded descending thoracic aortic aneurysm, and the bypass smooth and functional (red arrow and
blue arrow in Fig. 2).
Discussion
Aortitis syndrome predominantly affects young females and its etiology remains unclear.
Pathological studies have revealed inflammation and scar of the adventitia and the outer part of the
media, with a consequent thickening of the intima. This marked fibrosis and thickening of the arterial
wall causes stenosis and occlusion, or dilatation. Furthermore, as aortitis syndrome is a recurrent
disease, a number of problems regarding surgical management remain unsolved. These problems
concern steroid management, the most appropriate surgical procedures and materials to employ. In
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these adult patients, operative repair represents a surgical challenge and is associated with a high risk of
postoperative morbidity and mortality. Two surgical approaches, anatomic repair and extra-anatomic
bypass grafting, have been employed for repairing aortic disease[3,4]. Since a study by Wukasch et
al[5] in 1977, various techniques of extra-anatomic aortic bypass grafting have been introduced for
selected adult patients with disease of the aorta.
Although the results of surgery for aortitis syndrome presenting with an associated aortic
aneurysm have been improving [6], the operative procedures should be selected based on the extent of
the aneurysm, as conservation or incomplete resection of diseased, fragile, and inflamed tissue leaves a
persistent pathological focus that may be the cause of bleeding and pseudoaneurysmal formation.So,in
this case,the patient was treated with steroid therapy during the operation time to simplify the operation
and release the operation--trauma.
Several approaches have been used for single-stage repair of the entire thoracic aorta, including
median sternotomy with thoracotomy, the clamshell approach[7] and median sternotomy alone[8] In
consideration of our patient’s diffused loop-distorted which could no be exposed clearly, together with
more completely haemostasis we chose to operate via median sternotomy with lateral incision. A
median sternotomy incision not allows exposure of the distal descending thoracic aorta but by a lateral
incision. This operation which easy and simplify the operation and release the suffering and ach of
patient, may be a useful option for a diffuse thoracic aortic aneurysm when single-stage repair is
mandatory.
Conclusion
We describe an adult patient who underwent extra-anatomic bypass grafting for repair of
diffused aortic aneurysm through a median sternotomy and lateral incision approach. Extra-anatomic
aorta arch-descending thoracic aorta bypass grafting through a median sternotomy and lateral incision
approach is a safe, effective, and less postoperative complication technique for repairing diffused aortic
aneurysm in adult patients.
References
[1] Cooley DA. Retrograde replacement of the thoracic aorta. Tex Heart Inst J 1995;22:162–5.
[2] Nakano H, Shimakura T, Katsumata T, Shimamura Y, Yabuki A (1993) A case report -- successful
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surgical treatment of prosthetic aortic valve detachment with enlargement of sinuses of valsalva caused
by the recurrence of aortitis (in Japanese with English abstract). Nippon Kyobu Geka Gakkai Zasshi (J
Jpn Assn Thorac Surg) 41:523-527
[3] Connolly HM, Schaff HV, Izhar U, et al: Posterio pericardial ascending-to-descending aortic
bypass—An alternative surgical approach for complex coarctation of the aorta. Circulation
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[5] Wukasch DC, Cooley DA, Sandiford FM, et al: Ascending aorta-abdominal aorta bypass:
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[6] TOKUO KOSHINO, TERUHISA KAZUI, YUKIHIKO TAMIYA, JOHJI FUKADA, RYUJI
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Legend
Fig1. a loop-distorted aneurysm stuffing in mediastinum (red arrow), was noticeable in
Computed tomography (CT).
Fig2. Postoperative CT showed uncomplete obstruction of the excluded descending thoracic
aortic aneurysm(red arrow), and the bypass smooth and functional (blue arrow).
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Fig3. Postoperative CT showed the bypass smooth and functional (blue arrow).
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