Anterior Mediastinal Pseudoaneurysm

Author: Dawn S. Hui, MD; Richard Lee, MD; Hendrick Barner, MD
Institution: Saint Louis University
Date Reviewed: March 2014
Learning Domain: Adult Cardiac Surgery
Learning Objective: Chronic Type A Dissection post-CABG – Surgical Management
PowerPoint File: Chronic Type A Aortic Dissection

 

Discussion Points

  • Type A dissections after CABG
    • Techniques to avoid this complication
    • Sites of tear origination: proximal anastomoses, cannulation sites, cross-clamp site
    • Spontaneous vs. Iatrogenic - Potential sites of     origination: proximal anastomoses, cannulation sites,     cross-clamp site
    • More frequent with OPCAB?  Factors?  Should epi-aortic US be used routinely?
  • Principles of Re-operative CABG
    • Use of RIMA
    • Protection of LIMA: Clamp or leave alone?

 

  • Significance of competitive flow
    • Arterial vs venous
    • Impact of competitive flow on RCA conduit choice
  • At Risk Aortas? 
    • Some suggest aggressive replacement of at-risk aortas- atheromatous, dilated, calcified (Stanger et al, Eur J Cardiothorac Surg 2002; 21(3): 453-8) – controversial

 

Learning Points

  • Type A dissection post-cardiac surgery is rare; site of originating tear and risk factors not clearly identified in existing literature
  • Indications for operation in chronic type A dissection post-cardiac surgery differ from acute type A dissection
  • Prophylactic replacement of high-risk aortas should be considered

 

Readings

  • Tabry IF, Constantini EM.  Acute aortic dissection early after off-pump coronary surgery: true frequency underestimated? Tex Heart Inst J 2009; 36(5): 462-7.
  • Nishizaki I, Seki T, Abe T.  Successful surgical repair of delayed chronic type a dissection after previous coronary artery bypass grafting. Ann Thorac Cardiovasc Surg 2006 Aug;12(4):293-6.
  • Hirose H, Svensson LG, Lytle BW, Blackstone EH, Rajeswaran J, Cosrgove DM.  Aortic Dissection after previous cardiovascular surgery.  Ann Thorac Surg 2004; 78(6): 2099-105.
  • Chavanon O, Carrier M, Cariter R, Hebert Y, Pellerin M, Page P, Perrault LP.  Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery? Ann Thorac Surg 2001; 71(1): 117-21.
  • Hagl C, Ergin MA, Galla JD, Speilvogel D, Lansman S, Squitieri RP, Griepp RB.  Delayed chronic type A dissection following CABG: implications for evolving techniques of revascularization.  J Card Surg 2000; 15(5): 362-7.
  • Stanger O, Oberwalder P, Dacar D, Knez I, Rigler B.  Late dissection of the ascending aorta after previous cardiac surgery: risk, presentation, and outcome.  Eur J Cardiothorac Surg 2002; 21(3): 453-8.