A 66-year-old man had a history of arterial hypertension, transient cerebrovascular accident, and claudication in the lower limbs. Four months before we evaluated him in April of 2001, he presented with an episode of pancreatitis complicated by a pancreatic abscess that had to be surgically drained. Staphylococcus aureus grew in the culture taken from the abscess, and this infection was treated with antibiotic agents. The patient progressed satisfactorily; however, he was readmitted a month later with symptoms of thrombophlebitis of the left internal jugular vein and cellulitis of the adjacent subcutaneous tissue. He was treated with anticoagulants.
Two months after his return home, the patient was readmitted with substantial and recurrent hemoptysis, a weight loss of 10 kg during the 2-month interval, and an absence of fever. Fibrobronchoscopy was performed, during which a bronchial hemorrhage was provoked. Arteriography, performed with the aim of achieving selective embolization of the bronchial arteries, revealed saccular aneurysms of the aortic arch, which adhered to the apex pulmonis (). Another possible aneurysm was observed in the greater curvature of the ascending aorta, and yet a 3rd in the descending aorta at the diaphragm.
Fig. 1 Aortography shows the saccular aneurysm at the aortic arch (arrow).
A thoracic computed tomographic (CT) scan revealed a neoformation that affected the upper left pulmonary lobe; this solid mass, surrounded by atelectatic and cicatricial tissue, invaded the visceral pleura and maintained continuity with the aorta at the aortic arch. The aortic arch aneurysm so confirmed lay in the left lateral aortic wall, at the aperture of the left carotid and left subclavian arteries. The CT scan also confirmed the presence of a 2nd aneurysm in the greater curvature of the ascending aorta, adjacent to the superior vena cava, and a 3rd in the descending aorta at the diaphragm, above the celiac trunk (). In addition, CT imaging revealed a 4th lesion—an arteriosclerotic aneurysm of the abdominal aorta, which extended from a point below the renal arteries to the iliac bifurcation, which itself was heavily calcified.
Fig. 2 Thoracoabdominal computed tomographic scan shows another saccular aneurysm, at the vertebral part of the diaphragm and above the aperture of the celiac trunk.
The patient underwent urgent surgery via a median sternotomy. The right subclavian artery was cannulated for arterial perfusion. We found a fibrous, petrous mass, which completely united the aneurysmal wall of the aorta with the pericardium and the superior vena cava. The aneurysm had ruptured, expelling purulent material into the pericardium, which contained the rupture.
We sutured a 30-mm-diameter tube of woven Dacron to the supracoronary aorta with 3-0 Prolene continuous suture material. After lowering the systemic temperature to 20°C, we achieved systemic circulatory arrest (except for the supra-aortic trunks) and then initiated antegrade cerebral perfusion through the right subclavian artery. The aortic arch was opened along its complete length, to a point more than 5 cm distal to the left subclavian artery aperture. The aneurysm was also found to be ruptured in this segment, with the rupture contained by the pleura and by the pulmonary parenchyma, which had fibrosed on the aorta. We sectioned the descending aorta transversely and continuously sutured a 28-mm Dacron tubular prosthesis to it, in the form of an “elephant trunk” (with the prosthesis invaginated in such a manner that about 8 cm of the tube was left hanging in the descending aorta). After performing the anastomosis, we disinvaginated the prosthesis and made a knot in it distally, without attachment to the distal aorta. To this Dacron prosthesis we sutured the 3 supra-aortic trunks, after which we unclamped the brachiocephalic trunk and restored the systemic circulation. The 2 prostheses (for the ascending aorta and the aortic arch) were sutured together by end-to-end anastomosis. The rest of the procedure was completed without incident.
The duration of circulatory arrest was 48 min, of myocardial ischemia was 110 min, and of extracorporeal circulation was 156 min. The postoperative course was favorable, with extubation after 10 hours and normal neurologic and hemodynamic results.
Colonies of methicillin-sensitive S. aureus grew in the sample of pus taken from the aneurysm. The patient was therefore treated continuously for 6 weeks with rifampin, norfloxacin, and cloxacillin (in accordance with antibiogram results), before he underwent surgery on the descending aorta through a thoracic laparo-phrenicectomy. For this procedure, we did not use extracorporeal circulation or spinal cord protection. The distal thoracic aorta and the abdominal aorta were replaced with the use of sequential clamping techniques. After ligating the 2 intercostal branches, we clamped the distal thoracic aorta at a proximal level above the celiac trunk and at a distal level below the renal arteries (also controlling the visceral branches). Upon opening the aorta, we found an aneurysm that had ruptured through the aortic wall but had been contained by the viscera; this aneurysm was approximately 5 cm above the celiac trunk and showed no sign of active infection. We used a 22-mm Dacron tube to replace a segment, about 10 cm in length, of distal thoracic and proximal abdominal aorta, taking care to bevel the aortic ends proximally and distally and to respect the apertures of the visceral arteries. The clamping time was 35 min. The intercostal arteries were not reimplanted.
After that, we clamped the infrarenal aorta and replaced both iliac arteries and the abdominal aorta with a bifurcated 18-mm Dacron tube. The rest of the procedure was performed without incident. Again, the patient's postoperative course was favorable, and he did not suffer any neurologic sequelae. He was kept on antibiotic treatment for 6 weeks. At his 2-year follow-up visit, his laboratory and radiologic results were normal.