Download True Aneurysm of a Dacron Tube Graft 19 Years After Repair of

True Aneurysm of a Dacron Tube Graft 19 Years After Repair of Coarctation of
the Aorta
Saina Attaran, Mark Field, Manoj Kuduvalli, Michael Desmond, Aung Oo and Abbas
Rashid
Ann Thorac Surg 2010;90:1000-1001
DOI: 10.1016/j.athoracsur.2010.01.082
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1000
CASE REPORT
ATTARAN ET AL
ANEURYSM OF DACRON GRAFT
Ann Thorac Surg
2010;90:1000 –1
True Aneurysm of a Dacron Tube
Graft 19 Years After Repair of
Coarctation of the Aorta
Saina Attaran, MRCS, Mark Field, FRCS,
Manoj Kuduvalli, FRCS, Michael Desmond, FRCA,
Aung Oo, FRCS, and Abbas Rashid, FRCS
Department of Cardiothoracic Surgery, Liverpool Heart and
Chest Hospital NHS Trust, Liverpool, United Kingdom
We report a 31-year old woman who presented with acute
onset of shortness of breath 19 years after multiple
repairs of a preductal coarctation of the aorta using a
Dacron tube graft. Imaging studies showed an aneurysm
had developed in the tube graft. The aneurysmal tube
graft was replaced during an open repair.
(Ann Thorac Surg 2010;90:1000 –1)
© 2010 by The Society of Thoracic Surgeons
A
neurysmal changes of Dacron grafts are rare complications. It is believed that Dacron tube grafts do
not undergo aneurysmal changes over time or under
high pressure; however, that is not always the case.
FEATURE ARTICLES
A 31-year-old woman with history of multiple repairs of
a preductal coarctation of the aorta presented with acute
onset of shortness of breath. Except for stridor, her
physical examination was unremarkable.
She had undergone a left subclavian artery flap
through a left thoracotomy and closure of a patent ductus
arteriosus shortly after birth. Four years later, due to
recoarctation, a redo left-sided thoracotomy was performed to remove a shell of tissue from the coarcted area.
The coarctation was repaired with a Dacron gusset. At
the age of 13, she became symptomatic with dyspnea and
tiredness that necessitated a third operation through a
right thoracotomy. An extraanatomic bypass with a
16-mm Hemashield Dacron tube graft (Meadox Medicals
Inc, Oakland, NJ) from the junction of innominate artery
and ascending aorta to descending aorta was inserted.
This lasted for a further 19 years, until her admission to
our institution.
After a chest roentgenogram which showed a large
mass in the right hemithorax, a computed tomography
scan and a three-dimensional reconstruction computed
tomography image revealed an aneurysmal tube graft
measuring 6.5 cm in diameter with a possible pseudoaneurysm distally (Fig 1). Magnetic resonance imaging also
confirmed a possible aneurysm of the tube graft compressing the trachea.
She underwent a right-sided redo thoracotomy, which
revealed that the Hemashield graft had become aneurysmal (Fig 2). After systemic heparinization, cardiopulmo-
Fig 1. The aneurysmal tube graft is shown in a three-dimensional
computed tomography reconstruction image and in a regular computed tomography scan (inset) of the aneurysm.
nary bypass was established by cannulating the right
femoral artery for inflow and bicaval cannulation of the
right atrium for venous drainage. After deep hypothermic circulatory arrest (15°C), the aneurysmal graft was
replaced with a size 24 Gelweave graft (Vascutek, Inchinnan, United Kingdom), with the proximal and distal
anastomoses as in her previous operation.
The patient made a full recovery and was discharged
without any complications. She remains under yearly
surveillance follow-up with regular imaging.
Comment
Owing to the work of DeBakey, Dacron (polyethylene
terephthalate) aortic grafts have been the standard prosthesis for aortic replacement for more than 50 years [1].
Accepted for publication Jan 21, 2010.
Address correspondence to Dr Attaran, Liverpool Heart and Chest
Hospital NHS Trust, St. Thomas Dr, Liverpool, L14 3PE, United Kingdom;
e-mail: [email protected].
Fig 2. Intraoperative image demonstrates the enlarged Dacron graft.
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
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0003-4975/$36.00
doi:10.1016/j.athoracsur.2010.01.082
Ann Thorac Surg
2010;90:1001– 4
CASE REPORT
WEISS ET AL
PERICARDIAL CALCIUM CORONARY COMPRESSION
References
1. Hall CW, Liotta D, Chidoni JJ, DeBakey ME. Velour fabrics
applied to medicine. J Biomed Mater Res 1967;1:179 –96.
2. Nagano N, Cartier R, Zigras T. Mechanical properties and
microscopic findings of a Dacron graft explanted 27 years
after coarctation repair. J Thorac Cardiovasc Surg 2007;134:
1577– 8.
3. Nunn DB, Freeman MH, et al. Postoperative alteration in size
of Dacron aortic grafts. Ann Surg 1979;189:741– 4.
4. Berger K, Sauvage LR. Late fiber deterioration in Dacron
arterial grafts. Ann Surg 1981;193:477–91.
5. May J, Stephen M. Multiple aneurysms in Dacron velour
grafts. Arch Surg 1978;113:320 –1.
Postoperative Pericardial
Calcification Causing Diastolic
Coronary Compression
Sandra A. Weiss, MD, Allen S. Anderson, MD,
Jaishankar Raman, MD, PhD, and Neeraj Jolly, MD
Divisions of Cardiology and Cardiothoracic Surgery,
University of Chicago Medical Center, Chicago, Illinois
Diastolic compression of the coronary arteries is a rare
and likely acquired finding. Previous reports hypothesized that the artery becomes compressed against epicardial and pericardial scarring during ventricular filling,
which leads to reduced coronary blood flow and clinical
ischemia. We present two cases of isolated diastolic
coronary artery compression resulting from contact
Accepted for publication Feb 5, 2010.
Address correspondence to Dr Jolly, Section of Cardiology, University of
Chicago Medical Center, 5841 S Maryland Ave, MC 5076, Chicago,
IL 60637; e-mail: [email protected].
against postoperative pericardial reflections that became
calcified during the course of 10 to 20 years.
(Ann Thorac Surg 2010;90:1001– 4)
© 2010 by The Society of Thoracic Surgeons
S
ystolic coronary artery compression resulting from
intramyocardial coronary segments trapped by contracting cardiac muscle has a benign course with a
normal life expectancy, given that 85% of coronary blood
flow occurs during diastole [1]. Diastolic coronary artery
compression, however, is clinically rare and poorly reported. The limited cases describing this entity have
noted significant angiographic and clinical sequelae and
have generally been linked to constrictive pericarditis [2,
3]. We now describe two cases sharing a similar causality
of diastolic coronary compression and highlight the
pathophysiology and natural history of a hitherto undescribed process of postoperative pericardial calcification
resulting in this phenomenon.
Case Reports
Patient 1
A 44-year-old man status postorthotopic heart transplantation for dilated cardiomyopathy presented for routine
catheterization to exclude rejection [4]. Transplantation
occurred in 1998 and his immediate postoperative course
was complicated by acute, grade IIIA cellular rejection,
manifesting as pericardial effusion, congestive heart failure, and atrial and ventricular tachyarrhythmias. This
was treated successfully with murine monoclonal antiCD3 antibodies, followed by routine tacrolimus, mycophenolate, and prednisone.
Two years after transplant, the patient had exertional
dyspnea develop. Angiography noted diastolic compression of the first diagonal artery (Fig 1) with functional
significance confirmed by a decreased fractional flow
reserve, as well as abnormal stress myocardial perfusion.
Percutaneous coronary intervention was performed using a self-expanding (3.0 ⫻ 20 mm) radius stent (Boston
Scientific, Natick, MA), with complete angiographic and
clinical resolution. Pharmacologic stress demonstrated
significant improvement in myocardial perfusion to the
diagonal artery territory.
The patient remained asymptomatic and underwent
annual angiographic assessments through 2005, noting
30% in-stent re-stenosis in the diagonal artery stent, but
no further progression of coronary disease in the other
vessels. During the surveillance study in 2009, endomyocardial biopsy revealed no significant rejection. Coronary
angiography revealed no evidence of progressive coronary vasculopathy in the nonculprit arteries. However,
the diagonal artery stent now revealed nonobstructive
proximal deformation, consistent with an overriding calcified pericardial band newly visualized fluoroscopically
(Fig 2). Simultaneous right and left heart catheterization
was performed, excluding constrictive physiology.
The adenosine cardiac magnetic resonance imaging
study was performed revealing normal left ventricular size
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Downloaded from ats.ctsnetjournals.org by on January 25, 2012
0003-4975/$36.00
doi:10.1016/j.athoracsur.2010.02.045
FEATURE ARTICLES
Because of their tightly knitted fibers and the velour construction used in their internal surface, graft failure is not
expected by the surgeon, and the excellent long-term durability of these grafts has been reported previously [2].
However, there have also been reports that Dacron
grafts can undergo degenerative changes and increase in
size few months after the replacement [3]. This is a rare
phenomenon with an unknown incidence but significant
consequences. Dilatation and aneurysm of Dacron grafts
can be due to hydrostatic forces; pressure can result in
stretching the fiber and ultimately in fiber breakdown
and disintegration [4]. In addition, localized areas of
microscopic damage resulting in structural defects can
occur during handling, instrumentation, or can be due to
manufacturing defects [5].
In summary, we believe that patients undergoing an
operation to replace any parts of their aorta with Dacron
prostheses should be closely monitored, especially in cases
such as coarctation of the aorta with high hydrostatic
pressure gradients. Furthermore, special care should be
taken during the procedure and handling of the graft to
avoid any microinjuries and possible long-term graft failure.
1001
True Aneurysm of a Dacron Tube Graft 19 Years After Repair of Coarctation of
the Aorta
Saina Attaran, Mark Field, Manoj Kuduvalli, Michael Desmond, Aung Oo and Abbas
Rashid
Ann Thorac Surg 2010;90:1000-1001
DOI: 10.1016/j.athoracsur.2010.01.082
Updated Information
& Services
including high-resolution figures, can be found at:
http://ats.ctsnetjournals.org/cgi/content/full/90/3/1000
References
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