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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 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://ats.ctsnetjournals.org/cgi/content/full/90/3/1000 The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright © 2010 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259. Downloaded from ats.ctsnetjournals.org by on January 25, 2012 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 Downloaded from ats.ctsnetjournals.org by on January 25, 2012 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 This article cites 5 articles, 2 of which you can access for free at: http://ats.ctsnetjournals.org/cgi/content/full/90/3/1000#BIBL Citations This article has been cited by 1 HighWire-hosted articles: http://ats.ctsnetjournals.org/cgi/content/full/90/3/1000#otherarticle s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Great vessels http://ats.ctsnetjournals.org/cgi/collection/great_vessels Permissions & Licensing Requests about reproducing this article in parts (figures, tables) or in its entirety should be submitted to: http://www.us.elsevierhealth.com/Licensing/permissions.jsp or email: [email protected]. 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