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Surgical management of ascending aortic pseudoaneurysm in a 2-year-old boy: a case report
© The Author(s). 2018
Received: 28 October 2017
Accepted: 19 February 2018
Published: 17 April 2018
Aortic pseudoaneurysms are rare but life-threatening complications usually seen after cardiac surgery. The causes could be multifactorial such as infection or trauma.
We report the surgical management of a postoperative pseudoaneurysm of the ascending aorta caused by methicillin-resistant Staphylococcus aureus in a 2-year-old Middle Eastern boy who had undergone ventricular septal defect closure, subaortic membrane resection, and pulmonary artery de-banding. He was immediately operated on for resection of the aneurysm. A computed tomography scan at 2 months following surgery showed no aneurysm. Antibiotics were continued for 6 weeks and our patient was discharged with negative blood cultures.
Early diagnosis and appropriate treatment of such rare complication can be lifesaving.
Aortic pseudoaneurysms are rare, life-threatening sequelae of cardiac surgery . They can also occur as a result of infections, genetic disorders, or trauma [2–5]. They are uncommon in children. Several cases have been reported, most of which were secondary to bacterial endocarditis [6–8]. Our case highlights a rare postoperative complication that has not been reported previously in our region. Various management strategies have been suggested, including surgical and catheter-based interventions. Because of the age and size of our patient, and the infected nature of the lesion, we opted for surgical intervention. Timely diagnosis with effective surgical treatment in combination with antibiotic coverage can result in good survival without complications in such life-threatening situations.
Acquired aneurysms of the AsAo, although rarely seen, are most commonly found at cannulation sites and suture lines, particularly after repair of coarctation of the aorta . As reported these aneurysms are diagnosed with a high index of suspicion as symptoms are usually absent or nonspecific. They carry a high risk of mortality if diagnosed late and surgery is performed after the rupture . In the past, infected aneurysms were seen mostly as a result of infected endocarditis and repaired valvular diseases. These aneurysms can occur as direct invasion of aortic intima by circulating bacteria or through lymphatics in the presence of infection and mediastinitis. An added risk is therapeutic intervention like aortic cannulation . Similarly, our patient showed signs of infection on postoperative day 5 and his echocardiogram revealed a large aneurysm at the site of his aortic cannulation which was confirmed by CT angiogram. Our patient had MRSA growth confirmed by two blood and wound cultures, which along with other streptococcal species is one of the common organism isolated after mycotic aneurysm . It is extremely important to promptly diagnose these cases with a high index of suspicion especially after coarctation repair or history of aortic cannulation like in our case. An echocardiogram is a noninvasive, immediately available screening tool; cardiac CT angiogram is more sensitive. In our patient, with a high index of suspicion due to wound infection, an aortic cannulation and echocardiogram were done immediately and, later, cardiac CT was done to confirm the diagnosis.
Both immediate and long-term types of pseudoaneurysms have been reported . Various treatments of pseudoaneurysm are advocated in the literature. There is no well-defined treatment for this lesion in the pediatric population. Both percutaneous and surgical repairs have been advocated in the literature. However, percutaneous closure has been successfully reported in the adult population only [11, 12]. Surgical repair still remains the gold standard, especially because of the infected nature of the lesion that precludes the use of percutaneous devices. The main challenge for the surgeon is to plan an approach to the lesion without risking hemodynamic compromise, neurological insults that might be caused by air embolism, and hypotension secondary to bleeding or heart manipulation during dissection. Adhesions from previous cardiac surgery increase these risks. Various surgical approaches have been employed, such as femoral or neck cannulation to establish cardiopulmonary bypass, deep hypothermic circulatory arrest, and antegrade cerebral perfusion . Barth et al. in their case report of a similar case used the left common iliac artery for repair of a pseudoaneurysm of the AsAo in a 16-month-old girl .
Our patient had a tear at the site of aortic cannulation that appeared to be caused by bacterial infection with MRSA. Our approach included surface cooling, femoral cannulation mitigated by the use of a Gore-Tex graft for arterial cannulation, right atrial cannulation, and use of deep hypothermia. We found this method to be a safe and reproducible. A similar case was reported by Miyaji et al., where the common iliac artery was cannulated. Their case was postoperative mycotic pseudoaneurysm in the AsAo secondary to mediastinitis caused by MRSA after a modified Fontan procedure .
In conclusion, aortic pseudoaneurysms are rare but recognized complications of cardiac surgery that can be life-threatening. Prompt diagnosis and management, as in our case, can result in successful outcomes.
This study did not receive any grants.
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All materials are available for use by any other researcher.
KH and LF contributed the surgical part of the case report, MA in the initial drafting of the case report, AO contributed in images selection, SM and KN in the case report editing and literature review. All authors read and approved the final manuscript.
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Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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