Aortic pseudoaneurysm: clinical suspicion is life-saving

We have read with interest the article by Fukunaga and colleagues [1]. Prompt diagnosis allowed planning of a successful surgical strategy for this life-threatening disease.

This paper reminds us to keep on high alert level when evaluating a patient who previously underwent major cardiovascular surgery. Pseudoaneurysm is a subtle disease. Although surgical techniques and materials improved, and although prosthesis wrapping with aortic walls is seldom performed and infection of suture is rare in cardiac surgery, formation of a false aneurysm is not predictable and this complication may occur also very late. Every site of suture, needle puncture, or cannulation is potentially prone to develop a pseudoaneurysm. The discussion of the case offers a short, but good review of the matter. Only one potential site of formation is not contemplated: synthetic graft-to-synthetic graft anastomosis. This occurs, for example, when a segment of Dacron graft for arch replacement is sewn with the en-place graft of aortic root or when epiaortic vessels are reimplanted over a Dacron by interposition of a smaller graft. In our opinion, the absence of vital tissue in one side of a high-pressure high-shear stress anastomosis may potentially favour insurgence of this kind of complication.

Another attraction of this paper is the relevance of physical examination. Although the patient of this case report underwent regular instrumental work-up, a superior vena cava syndrome was noticed [2]. Extrinsic compression by the pseudoaneurysm was the cause of jugular distension and just detection itself was already a life-saving act. Emergency redo surgery in case of a ruptured aortic pseudoaneurysm is very challenging (mediastinal adherences that hamper prompt domination of the bleeding site, risk of entering aorta in case of decubitus with the sternum, massive bleeding that prevents valid resuscitative manoeuvres or effective peripheral extracorporeal circulation). On the contrary, surgery before rupture allows to plan a complex, but potentially curative operation.

Recently, approaches by means of a stent graft or septal occluder have been used to treat also ascending aorta false aneurysm. Endovascular approaches may represent a viable alternative for the high risk patient with suitable anatomy; however they should not be used in the presence of mass effect syndromes when the relief of the compression is required besides vascular repair. Indeed, only the open surgical treatment can provide it.

The formation of a pseudoaneurysm is a rare but serious complication of all cardiovascular operations. Late onset is very insidious and ‘anomalous’ symptoms may appear, especially after intrathoracic operations. This occurs because false aneurysms come up against postoperative adherences that influence its expansion, they grow along unpredictable routes and they cause compression of various intrathoracic structures giving a wide spectrum of symptoms and signs. Therefore, after complex cardiac surgery, qualified instrumental and clinical follow-up in cooperation with cardiac surgeons are required. A prompt recognition defuses a lethal danger and we support the authors’ position.

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