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Radiology: Cardiothoracic Imaging logoLink to Radiology: Cardiothoracic Imaging
. 2019 Oct 31;1(4):e190080. doi: 10.1148/ryct.2019190080

Mimics of Complications in the Postsurgical Aorta at CT

Daniel B Green 1,✉, Daniel Vargas 1, T Brett Reece 1, Constantine A Raptis 1, W Russell Johnson 1, Quynh A Truong 1
PMCID: PMC7977720  PMID: 33778523

Abstract

Various surgical techniques of the aorta result in expected imaging appearances on CT images that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of these mimics are essential for accurate interpretation. CT imaging techniques such as electrocardiographic gating and inclusion of a precontrast series can help distinguish an expected postsurgical finding from a complication. Information in the medical record, particularly the operative note, can clarify challenging cases with unusual imaging features. This review article provides examples of expected postsurgical findings at CT mimicking complications.

© RSNA, 2019

Summary

Expected postsurgical CT findings of the aorta mimic complications such as pseudoaneurysm, perigraft abscess, and dissection.

Essentials

  • ■ Perfusion grafts are tied off at the end of aortic surgery and mimic pseudoaneurysms at postoperative imaging.

  • ■ Fluid collecting in the space between an aortic graft and a muscle flap or enclosed aneurysm sac mimics an abscess but should not persist beyond a few months.

  • ■ Hemostatic agents surrounding an aortic graft contain droplets of gas, mimicking an abscess due to a gas-forming organism.

  • ■ The graft suspended in the proximal descending thoracic aorta as part of the elephant trunk procedure and reverse elephant trunk procedure mimics an aortic dissection.

  • ■ Electrocardiographic gating, precontrast imaging, and information in the patient’s medical record are helpful in differentiating postsurgical complications from their mimics.

Introduction

Major complications of the postsurgical aorta, such as pseudoaneurysm, perigraft abscess, and dissection, are rare but associated with significant morbidity. Conversely, various operative techniques result in anticipated imaging appearances that resemble these same complications. The potential to avoid increased surveillance or repeat operation highlights the importance of identifying expected findings and distinguishing them from adverse findings. The purpose of this article was to review surgical techniques with postoperative imaging findings that mimic complications and the clinical scenarios in which they are performed.

Imaging Techniques

CT angiography is the main modality used for surveillance of the postsurgical aorta. Precontrast imaging should be included in at least the first postoperative scan and may be helpful in all postoperative evaluations of the aorta. With dual-source dual-energy CT scanners, it is possible to generate virtual noncontrast images, eliminating the need for a separate precontrast acquisition (1). Electrocardiographic (ECG) gating reduces motion artifact and improves evaluation of the aortic root and ascending aorta. Some patients, particularly younger ones with connective tissue diseases who require annual surveillance, opt for MRI rather than CT to avoid ionizing radiation. Although complications of the postsurgical aorta and their mimics can also be identified at contrast material–enhanced or noncontrast MR angiography, this article focuses on CT.

Mimics of Pseudoaneurysm

Coronary Button

The “button technique” is currently the standard approach for coronary ostial reimplantation during aortic root repair. The coronary arteries are excised with a collar of native aorta and then sutured to the ascending aorta graft as a Carrel patch by an end-to-side anastomosis (2). The coronary button technique has significantly reduced the incidence of anastomotic stenosis, dehiscence, and pseudoaneurysm by allowing for increased mobility of the coronary arteries and reducing tension on the coronary anastomosis (3).

The new coronary ostia, consisting of native aortic tissue, typically have a greater diameter than the original coronary artery segments that follow. The imaging appearance of the larger coronary ostia is reminiscent of an actual garment button and should not be confused with an anastomotic pseudoaneurysm or true aneurysm (Fig 1). An anastomotic pseudoaneurysm is extraluminal, blind ending, and adjacent to the coronary button but does not give rise to the coronary artery. ECG gating is helpful in distinguishing a coronary button from a pseudoaneurysm by reducing cardiac motion artifact.

Figure 1a:

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(a) Illustration of the modified Bentall procedure with coronary buttons (arrows). (Illustration courtesy of Marissa Craft Green.) (b) Coronal contrast-enhanced CT image in a 70-year-old man after modified Bentall procedure shows left and right coronary buttons (arrows). The ostia are larger than the more distal native coronary arteries. This appearance is reminiscent of an actual button. (c) Sagittal CT image in a different patient. A coronary button should not be mistaken for a coronary anastomotic pseudoaneurysm (white arrow), which is blind ending and adjacent to a coronary artery (black arrow) but does not give rise to a coronary artery. (d) A coronal contrast-enhanced CT image in a 36-year-old woman with Marfan syndrome after modified Bentall procedure shows a 2.4-cm left coronary button aneurysm and a 1.6-cm right coronary button aneurysm (arrows).

Figure 1b:

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(a) Illustration of the modified Bentall procedure with coronary buttons (arrows). (Illustration courtesy of Marissa Craft Green.) (b) Coronal contrast-enhanced CT image in a 70-year-old man after modified Bentall procedure shows left and right coronary buttons (arrows). The ostia are larger than the more distal native coronary arteries. This appearance is reminiscent of an actual button. (c) Sagittal CT image in a different patient. A coronary button should not be mistaken for a coronary anastomotic pseudoaneurysm (white arrow), which is blind ending and adjacent to a coronary artery (black arrow) but does not give rise to a coronary artery. (d) A coronal contrast-enhanced CT image in a 36-year-old woman with Marfan syndrome after modified Bentall procedure shows a 2.4-cm left coronary button aneurysm and a 1.6-cm right coronary button aneurysm (arrows).

Figure 1c:

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(a) Illustration of the modified Bentall procedure with coronary buttons (arrows). (Illustration courtesy of Marissa Craft Green.) (b) Coronal contrast-enhanced CT image in a 70-year-old man after modified Bentall procedure shows left and right coronary buttons (arrows). The ostia are larger than the more distal native coronary arteries. This appearance is reminiscent of an actual button. (c) Sagittal CT image in a different patient. A coronary button should not be mistaken for a coronary anastomotic pseudoaneurysm (white arrow), which is blind ending and adjacent to a coronary artery (black arrow) but does not give rise to a coronary artery. (d) A coronal contrast-enhanced CT image in a 36-year-old woman with Marfan syndrome after modified Bentall procedure shows a 2.4-cm left coronary button aneurysm and a 1.6-cm right coronary button aneurysm (arrows).

Figure 1d:

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(a) Illustration of the modified Bentall procedure with coronary buttons (arrows). (Illustration courtesy of Marissa Craft Green.) (b) Coronal contrast-enhanced CT image in a 70-year-old man after modified Bentall procedure shows left and right coronary buttons (arrows). The ostia are larger than the more distal native coronary arteries. This appearance is reminiscent of an actual button. (c) Sagittal CT image in a different patient. A coronary button should not be mistaken for a coronary anastomotic pseudoaneurysm (white arrow), which is blind ending and adjacent to a coronary artery (black arrow) but does not give rise to a coronary artery. (d) A coronal contrast-enhanced CT image in a 36-year-old woman with Marfan syndrome after modified Bentall procedure shows a 2.4-cm left coronary button aneurysm and a 1.6-cm right coronary button aneurysm (arrows).

Because a coronary button is frequently composed of degenerative aortic tissue, the new coronary ostium may continue to enlarge after reimplantation and develop into a true aneurysm. While there is no specific size threshold for a coronary button aneurysm, all reported cases have exceeded 10 mm in diameter and were noted to enlarge over time (4–6). Patients with Marfan syndrome or other connective tissue diseases have more fragile aortic tissue and are at increased risk for coronary button aneurysm formation. Coronary button aneurysms have an increased risk of rupture, although there are currently no guidelines for timing of surgical revision.

Felt Buttresses

Made of polytetrafluoroethylene (Teflon; DuPont Pharmaceuticals), felt pledgets and rings are used in vascular surgery to reinforce suture lines and improve hemostasis (7). Felt pledgets are placed at cannulation sites with pledgeted purse-string sutures, most frequently in the ascending aorta. Cannulation of the ascending aorta is used to deliver antegrade cardioplegic solution, suction retrograde cardioplegic solution, vent the left ventricle, and de-air the aorta (8).

A felt pledget is a small, round, high-attenuating object usually along the anterior wall of the aortic graft. Because of their shape and high attenuation, felt pledgets resemble a small outpouching of contrast material, mimicking a pseudoaneurysm (Fig 2). Recognizing the typical location of a felt pledget along the anterior wall of an ascending aorta graft helps distinguish it from a pseudoaneurysm. The presence of an identical high-attenuating object at precontrast imaging excludes a pseudoaneurysm. If precontrast imaging is not available, adjusting window settings may differentiate felt from intravenous contrast material. Although pledgets are a common mimic of a pseudoaneurysm, they are foreign bodies and may rarely become infected, resulting in an actual pseudoaneurysm (9,10).

Figure 2a:

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Three axial CT images in a 72-year-old man after aortic valve replacement at the same level show a felt pledget (arrows) along the anterior wall of the ascending aorta. The pledget is the same attenuation as intraluminal contrast material on different window settings (a, b), mimicking a pseudoaneurysm. (c) On the precontrast image, the pledget is hyperattenuating, proving it is surgical material rather than a pseudoaneurysm.

Figure 2b:

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Three axial CT images in a 72-year-old man after aortic valve replacement at the same level show a felt pledget (arrows) along the anterior wall of the ascending aorta. The pledget is the same attenuation as intraluminal contrast material on different window settings (a, b), mimicking a pseudoaneurysm. (c) On the precontrast image, the pledget is hyperattenuating, proving it is surgical material rather than a pseudoaneurysm.

Figure 2c:

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Three axial CT images in a 72-year-old man after aortic valve replacement at the same level show a felt pledget (arrows) along the anterior wall of the ascending aorta. The pledget is the same attenuation as intraluminal contrast material on different window settings (a, b), mimicking a pseudoaneurysm. (c) On the precontrast image, the pledget is hyperattenuating, proving it is surgical material rather than a pseudoaneurysm.

Felt rings are wrapped around proximal and distal anastomoses and appear as circumferential high-attenuation material on both pre- and postcontrast images. While they may also mimic a pseudoaneurysm on postcontrast images, the felt ring or even the slightly hyperattenuating graft material along the perimeter of the aorta can occasionally resemble an intramural hematoma on precontrast images (11).

Occluded Coronary Bypass Graft

During coronary artery bypass grafting, saphenous vein grafts (SVGs) are attached to the aorta in a similar location as a felt pledget. Bypass graft thrombosis is common, with up to 13.6% of SVGs occluded at 1 year and up to 18.6% of SVGs occluded at 7.5 years (12–14). When a bypass graft thromboses but a short patent lumen remains at the ostium, the appearance mimics a pseudoaneurysm.

In an acutely thrombosed graft, the nonenhancing portion of the vessel may be seen distal to the contrast material outpouching. Over time, however, the thrombosed vessel becomes less apparent and only the patent ostium remains, mimicking a pseudoaneurysm (Fig 3). The presence of sternal wires, surgical clips, and at least one other coronary artery bypass graft are clues to the patient’s surgical history and raises the possibility of a thrombosed graft. Bypass graft markers are metallic rings that may also be placed at the proximal graft anastomosis. The patient’s medical record should also state how many bypass grafts were utilized. An aortotomy pseudoaneurysm in this location is rare, typically larger, and may be lined by thrombus (Fig 3).

Figure 3a:

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(a) Axial and (b) sagittal contrast-enhanced CT images in a 78-year-old man after two-vessel coronary bypass show an occluded bypass graft as a luminal outpouching along the anterior wall of the ascending aorta (white arrows), mimicking a pseudoaneurysm. The presence of another bypass graft (black arrow) suggests prior coronary artery bypass grafting. (c) A 59-year-old man after three-vessel coronary bypass presented with chest pain. A similar contrast material outpouching (solid white arrow) mimics a pseudoaneurysm on a postcontrast multiplanar reformatted CT image (c); however, the thrombosed segment can be seen more distally (solid black arrow). Other bypass grafts (dashed arrows) are again a clue to prior bypass grafting. (d) An axial contrast-enhanced CT image in a different patient shows an aortotomy pseudoaneurysm in the same region (black arrow). The pseudoaneurysm is larger than the occluded bypass graft and lined by thrombus (white arrow).

Figure 3b:

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(a) Axial and (b) sagittal contrast-enhanced CT images in a 78-year-old man after two-vessel coronary bypass show an occluded bypass graft as a luminal outpouching along the anterior wall of the ascending aorta (white arrows), mimicking a pseudoaneurysm. The presence of another bypass graft (black arrow) suggests prior coronary artery bypass grafting. (c) A 59-year-old man after three-vessel coronary bypass presented with chest pain. A similar contrast material outpouching (solid white arrow) mimics a pseudoaneurysm on a postcontrast multiplanar reformatted CT image (c); however, the thrombosed segment can be seen more distally (solid black arrow). Other bypass grafts (dashed arrows) are again a clue to prior bypass grafting. (d) An axial contrast-enhanced CT image in a different patient shows an aortotomy pseudoaneurysm in the same region (black arrow). The pseudoaneurysm is larger than the occluded bypass graft and lined by thrombus (white arrow).

Figure 3c:

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(a) Axial and (b) sagittal contrast-enhanced CT images in a 78-year-old man after two-vessel coronary bypass show an occluded bypass graft as a luminal outpouching along the anterior wall of the ascending aorta (white arrows), mimicking a pseudoaneurysm. The presence of another bypass graft (black arrow) suggests prior coronary artery bypass grafting. (c) A 59-year-old man after three-vessel coronary bypass presented with chest pain. A similar contrast material outpouching (solid white arrow) mimics a pseudoaneurysm on a postcontrast multiplanar reformatted CT image (c); however, the thrombosed segment can be seen more distally (solid black arrow). Other bypass grafts (dashed arrows) are again a clue to prior bypass grafting. (d) An axial contrast-enhanced CT image in a different patient shows an aortotomy pseudoaneurysm in the same region (black arrow). The pseudoaneurysm is larger than the occluded bypass graft and lined by thrombus (white arrow).

Figure 3d:

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(a) Axial and (b) sagittal contrast-enhanced CT images in a 78-year-old man after two-vessel coronary bypass show an occluded bypass graft as a luminal outpouching along the anterior wall of the ascending aorta (white arrows), mimicking a pseudoaneurysm. The presence of another bypass graft (black arrow) suggests prior coronary artery bypass grafting. (c) A 59-year-old man after three-vessel coronary bypass presented with chest pain. A similar contrast material outpouching (solid white arrow) mimics a pseudoaneurysm on a postcontrast multiplanar reformatted CT image (c); however, the thrombosed segment can be seen more distally (solid black arrow). Other bypass grafts (dashed arrows) are again a clue to prior bypass grafting. (d) An axial contrast-enhanced CT image in a different patient shows an aortotomy pseudoaneurysm in the same region (black arrow). The pseudoaneurysm is larger than the occluded bypass graft and lined by thrombus (white arrow).

Oversewn Side Branch

In total aortic arch replacement, a side branch built into the graft provides antegrade systemic perfusion after the distal anastomosis is completed (15). Upon completion of the surgery, the side branch is divided and ligated with a suture or staple line. Postoperative imaging reveals an outpouching of contrast material along the aortic arch, mimicking a pseudoaneurysm (Fig 4). The length of the outpouching depends on the length of residual graft.

Figure 4a:

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(a) Illustration of an intraoperative total arch repair. The perfusion side branch (arrow) will be divided and tied off at the conclusion of the surgery, resulting in a small outpouching on postoperative images. (Illustration courtesy of Marissa Craft Green.) (b–c) Images in a 67-year-old man after total aortic arch repair and endovascular repair of the descending thoracic aorta. (b) Axial and (c) coronal postcontrast CT images show a small oversewn side branch mimicking a pseudoaneurysm (white arrows). A small amount of linear suture can occasionally be seen at the blind end (black arrow). (d–e) Images in a 57-year-old woman after hemiarch repair for type A aortic dissection. (d) Pre- and (e) postcontrast coronal CT images show the oversewn side branch along the lesser curvature of the distal ascending aorta (white arrows). The location is more proximal than for total aortic arch repair. Note the hyperattenuating graft material on the precontrast image (black arrow in d).

Figure 4b:

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(a) Illustration of an intraoperative total arch repair. The perfusion side branch (arrow) will be divided and tied off at the conclusion of the surgery, resulting in a small outpouching on postoperative images. (Illustration courtesy of Marissa Craft Green.) (b–c) Images in a 67-year-old man after total aortic arch repair and endovascular repair of the descending thoracic aorta. (b) Axial and (c) coronal postcontrast CT images show a small oversewn side branch mimicking a pseudoaneurysm (white arrows). A small amount of linear suture can occasionally be seen at the blind end (black arrow). (d–e) Images in a 57-year-old woman after hemiarch repair for type A aortic dissection. (d) Pre- and (e) postcontrast coronal CT images show the oversewn side branch along the lesser curvature of the distal ascending aorta (white arrows). The location is more proximal than for total aortic arch repair. Note the hyperattenuating graft material on the precontrast image (black arrow in d).

Figure 4c:

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(a) Illustration of an intraoperative total arch repair. The perfusion side branch (arrow) will be divided and tied off at the conclusion of the surgery, resulting in a small outpouching on postoperative images. (Illustration courtesy of Marissa Craft Green.) (b–c) Images in a 67-year-old man after total aortic arch repair and endovascular repair of the descending thoracic aorta. (b) Axial and (c) coronal postcontrast CT images show a small oversewn side branch mimicking a pseudoaneurysm (white arrows). A small amount of linear suture can occasionally be seen at the blind end (black arrow). (d–e) Images in a 57-year-old woman after hemiarch repair for type A aortic dissection. (d) Pre- and (e) postcontrast coronal CT images show the oversewn side branch along the lesser curvature of the distal ascending aorta (white arrows). The location is more proximal than for total aortic arch repair. Note the hyperattenuating graft material on the precontrast image (black arrow in d).

Figure 4d:

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(a) Illustration of an intraoperative total arch repair. The perfusion side branch (arrow) will be divided and tied off at the conclusion of the surgery, resulting in a small outpouching on postoperative images. (Illustration courtesy of Marissa Craft Green.) (b–c) Images in a 67-year-old man after total aortic arch repair and endovascular repair of the descending thoracic aorta. (b) Axial and (c) coronal postcontrast CT images show a small oversewn side branch mimicking a pseudoaneurysm (white arrows). A small amount of linear suture can occasionally be seen at the blind end (black arrow). (d–e) Images in a 57-year-old woman after hemiarch repair for type A aortic dissection. (d) Pre- and (e) postcontrast coronal CT images show the oversewn side branch along the lesser curvature of the distal ascending aorta (white arrows). The location is more proximal than for total aortic arch repair. Note the hyperattenuating graft material on the precontrast image (black arrow in d).

Figure 4e:

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(a) Illustration of an intraoperative total arch repair. The perfusion side branch (arrow) will be divided and tied off at the conclusion of the surgery, resulting in a small outpouching on postoperative images. (Illustration courtesy of Marissa Craft Green.) (b–c) Images in a 67-year-old man after total aortic arch repair and endovascular repair of the descending thoracic aorta. (b) Axial and (c) coronal postcontrast CT images show a small oversewn side branch mimicking a pseudoaneurysm (white arrows). A small amount of linear suture can occasionally be seen at the blind end (black arrow). (d–e) Images in a 57-year-old woman after hemiarch repair for type A aortic dissection. (d) Pre- and (e) postcontrast coronal CT images show the oversewn side branch along the lesser curvature of the distal ascending aorta (white arrows). The location is more proximal than for total aortic arch repair. Note the hyperattenuating graft material on the precontrast image (black arrow in d).

In a hemiarch repair, the oversewn or tied-off side branch serves the same purpose but is located more proximally—along the lesser curvature of the distal ascending aorta. Precontrast images may show hyperattenuating graft material peripherally or a thin suture or staple at the end of the branch (Fig 4). If the imaging result is unclear, the operative report should state that a perfusion branch was used and then ligated at the end of the surgery. Oversewn perfusion grafts may also be seen in other segments of the aorta as well as other vessels, such as the brachiocephalic trunk or subclavian artery.

Mimics of Perigraft Abscess

Perigraft Hematoma

Profuse bleeding is not uncommon during aortic surgery. Although clots are suctioned as best as possible, some hematoma may remain or rebleeding may occur postoperatively. In these instances, postoperative imaging is likely to show residual hematomas, particularly around the graft. Depending on the age of the hematoma, the appearance can be similar to that of fluid with a hyperattenuating rim, mimicking an abscess (Fig 5). Precontrast imaging proves that the hyperattenuating rim is not actually enhancing, reducing the likelihood of an abscess. The patient’s medical record may also detail significant intraoperative bleeding in the operative report or increased chest tube output or anemia in postoperative progress notes. Large postoperative hematomas may take several months to resolve. If there is continued clinical suspicion for perigraft infection, fluorodeoxyglucose PET/CT offers greater sensitivity and specificity than indium 111–labeled leukocyte scanning (16–18).

Figure 5a:

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(a) Axial contrast-enhanced CT image in a 67-year-old man with a large amount of bleeding during ascending aorta repair for type A dissection mimics a rim-enhancing perigraft abscess (arrows). However, the corresponding (b) precontrast image shows that the collection is peripherally hyperattenuating (arrows) rather than enhancing and therefore a hematoma.

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(a) Axial contrast-enhanced CT image in a 67-year-old man with a large amount of bleeding during ascending aorta repair for type A dissection mimics a rim-enhancing perigraft abscess (arrows). However, the corresponding (b) precontrast image shows that the collection is peripherally hyperattenuating (arrows) rather than enhancing and therefore a hematoma.

Muscle Flap for Graft Infection

Some cases of aortic graft infection, such as those infected by Pseudomonas species or methicillin-resistant Staphylococcus aureus, are treated with graft excision, meticulous debridement, and in situ reconstruction of a biologic conduit (eg, homograft or pericardial graft) or interposition graft with vascularized muscle transposition (19–21). In the thorax, latissimus dorsi or serratus anterior muscle flaps are most commonly used. The muscle flap promotes healing by increasing vascular supply and oxygen tension, enhancing antimicrobial therapy, protecting the wound from contamination, and protecting the graft from desiccation and thrombosis (22).

After surgery, the space between the graft and muscle flap can accumulate fluid. Perigraft fluid is an expected imaging finding for up to a few months and should not immediately be mistaken for an abscess (23). The muscle flap encircling the perigraft fluid should also not be mistaken for rim enhancement (Fig 6). Inflammatory change in the chest wall is a clue to a harvested muscle flap. Omental flaps and pleuropericardial vascularized pedicles are occasionally used for treatment of graft infections or fistulas and may also result in perigraft fluid (21). Depending on where the flap originates from, the appearance can also mimic a hernia (Fig 6).

Figure 6a:

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(a–b) Images in a 75-year-old woman after explantation of an infected aortic stent graft and subsequent placement of a new interposition graft with left serratus anterior muscle flap translocation. (a) Axial contrast-enhanced CT image 1 week after surgery shows fluid in the perigraft space (arrows) formed by the muscle flap. Nine weeks after surgery, (b) an axial contrast-enhanced CT shows the fluid has mostly resolved and the muscle flap is more apparent (arrows). (c–e) Images in a 57-year-old man with an omental flap (white arrows) during aortic root revision for graft infection. (c, d) Axial and (e) sagittal postcontrast CT images show the pedicle crossing the diaphragm into the mediastinum, mimicking a Morgagni hernia. The omental fat has a different attenuation than the mediastinal fat containing small lymph nodes (black arrow in d).

Figure 6b:

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(a–b) Images in a 75-year-old woman after explantation of an infected aortic stent graft and subsequent placement of a new interposition graft with left serratus anterior muscle flap translocation. (a) Axial contrast-enhanced CT image 1 week after surgery shows fluid in the perigraft space (arrows) formed by the muscle flap. Nine weeks after surgery, (b) an axial contrast-enhanced CT shows the fluid has mostly resolved and the muscle flap is more apparent (arrows). (c–e) Images in a 57-year-old man with an omental flap (white arrows) during aortic root revision for graft infection. (c, d) Axial and (e) sagittal postcontrast CT images show the pedicle crossing the diaphragm into the mediastinum, mimicking a Morgagni hernia. The omental fat has a different attenuation than the mediastinal fat containing small lymph nodes (black arrow in d).

Figure 6c:

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(a–b) Images in a 75-year-old woman after explantation of an infected aortic stent graft and subsequent placement of a new interposition graft with left serratus anterior muscle flap translocation. (a) Axial contrast-enhanced CT image 1 week after surgery shows fluid in the perigraft space (arrows) formed by the muscle flap. Nine weeks after surgery, (b) an axial contrast-enhanced CT shows the fluid has mostly resolved and the muscle flap is more apparent (arrows). (c–e) Images in a 57-year-old man with an omental flap (white arrows) during aortic root revision for graft infection. (c, d) Axial and (e) sagittal postcontrast CT images show the pedicle crossing the diaphragm into the mediastinum, mimicking a Morgagni hernia. The omental fat has a different attenuation than the mediastinal fat containing small lymph nodes (black arrow in d).

Figure 6d:

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(a–b) Images in a 75-year-old woman after explantation of an infected aortic stent graft and subsequent placement of a new interposition graft with left serratus anterior muscle flap translocation. (a) Axial contrast-enhanced CT image 1 week after surgery shows fluid in the perigraft space (arrows) formed by the muscle flap. Nine weeks after surgery, (b) an axial contrast-enhanced CT shows the fluid has mostly resolved and the muscle flap is more apparent (arrows). (c–e) Images in a 57-year-old man with an omental flap (white arrows) during aortic root revision for graft infection. (c, d) Axial and (e) sagittal postcontrast CT images show the pedicle crossing the diaphragm into the mediastinum, mimicking a Morgagni hernia. The omental fat has a different attenuation than the mediastinal fat containing small lymph nodes (black arrow in d).

Figure 6e:

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(a–b) Images in a 75-year-old woman after explantation of an infected aortic stent graft and subsequent placement of a new interposition graft with left serratus anterior muscle flap translocation. (a) Axial contrast-enhanced CT image 1 week after surgery shows fluid in the perigraft space (arrows) formed by the muscle flap. Nine weeks after surgery, (b) an axial contrast-enhanced CT shows the fluid has mostly resolved and the muscle flap is more apparent (arrows). (c–e) Images in a 57-year-old man with an omental flap (white arrows) during aortic root revision for graft infection. (c, d) Axial and (e) sagittal postcontrast CT images show the pedicle crossing the diaphragm into the mediastinum, mimicking a Morgagni hernia. The omental fat has a different attenuation than the mediastinal fat containing small lymph nodes (black arrow in d).

Perigraft Seroma

A perigraft seroma is a persistent fluid collection surrounding a prosthetic vascular graft. Although most often associated with subcutaneously tunneled grafts, such as axillofemoral bypass grafts and dialysis access grafts, it is a rare complication of aortic surgery (24). Whereas the aorta is typically completely excised in thoracic aorta repair, during open abdominal aortic aneurysm repair, the aneurysm sac is closed around an inclusion graft to decrease the likelihood of aortoenteric fistula. Fluid can accumulate and persist between the graft and vessel wall, mimicking an abscess. Perigraft seroma of the thoracic aorta has also been described following interposition graft repair (25,26).

The pathogenesis of perigraft seroma is unclear but is thought to involve failure of graft incorporation into the surrounding tissues and/or ultrafiltration of fluid through graft pores. Proposed mechanisms include low-grade infection with biofilm formation along the graft without systemic sepsis (27), fibroblast inhibition (28,29), immunologic response to graft material (29,30), and improper graft handling (31). Potential complications of perigraft seroma include intractable pain, sac rupture, and graft compression or thrombosis (24,32).

Perigraft fluid surrounding an inclusion graft is not an uncommon imaging finding in the immediate postoperative period; however, it should resolve by about 3 months. Persistent fluid in the perigraft space should raise suspicion for a perigraft seroma (33). In a series of 20 patients with perigraft seroma after open abdominal aortic aneurysm repair, the following diagnostic imaging criteria was used: (a) presence of a perigraft collection for more than 3 months, (b) diameter 3 cm or greater, and (c) attenuation less than 25 HU (24). The amount of fluid may increase or remain stable over time. Enhancement of the wall of the native aorta mimics rim enhancement of an abscess; however, atherosclerotic calcifications would not be present in the wall of an abscess and may be more easily appreciated without contrast material (Fig 7). Absence of contrast material leakage into the perigraft space must also be demonstrated to exclude a pseudoaneurysm.

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(a) Axial and (b) coronal contrast-enhanced CT images in a 54-year-old man after open repair of the infrarenal aorta and common iliac arteries 6 months prior show a persisting perigraft fluid collection, presumed to be a seroma. Atherosclerotic calcifications along the wall of the native aorta (arrows) would not be present in an abscess.

Figure 7b:

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(a) Axial and (b) coronal contrast-enhanced CT images in a 54-year-old man after open repair of the infrarenal aorta and common iliac arteries 6 months prior show a persisting perigraft fluid collection, presumed to be a seroma. Atherosclerotic calcifications along the wall of the native aorta (arrows) would not be present in an abscess.

Most patients with perigraft seroma are asymptomatic and require no treatment. For symptomatic patients, fluid may recur after simple aspiration, and sclerosing agents may put the graft at risk. Successful treatments have included discontinuation of antiplatelet or anticoagulation therapy (24,34), fibrin glue application (25), endovascular coverage of the graft (25), seroma evacuation followed by marsupialization to the peritoneal wall (31), and replacement of the graft with another graft of a different material.

Hemostatic Agents

Hemostatic agents help control intraoperative bleeding not controlled by cautery or ligation. A gelatin bioabsorbable sponge (Gelfoam; Pfizer) is made of a water-insoluble, purified porcine skin product that aids hemostasis by forming an artificial clot and providing a mechanical matrix for platelet aggregation (35). A similar hemostatic gauze (Surgicel; Ethicon) is made of oxidized regenerated cellulose (36). These materials are left in the surgical field, unlike collagen-containing hemostatic agents that must be removed before closure.

The normal imaging appearance of in situ gelatin bioabsorbable sponge (Gelfoam) and hemostatic gauze (Surgicel) includes droplets of gas, which can raise suspicion for a gas-containing abscess when interspersed within perigraft fluid (37) (Fig 8). Perigraft gas is an expected postoperative finding until about 6 weeks when it becomes more suggestive of infection (37). When unexpected perigraft gas is identified at CT, the operative report should be reviewed for the use of a hemostatic agent, and the surgeon can offer clarification as needed. Perigraft fluid and debris are rarely the result of a foreign body reaction to the hemostatic material itself (38,39).

Figure 8:

Figure 8:

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Axial contrast-enhanced CT image in a 28-year-old man with Marfan syndrome after ascending aorta repair for type A aortic dissection. Perigraft fluid with droplets of gas (arrows) is due to a gelatin bioabsorbable sponge (Gelfoam) placed intraoperatively for uncontrollable bleeding, mimicking an abscess.

Some imaging features are suggestive of a hemostatic agent rather than a gas-forming abscess. Hemostatic agents are denser than pure gas with attenuation ranging from −104 to −458 HU (40). Although the amount of material used depends on how much is needed for a particular case and the shape depends on how it is cut, the gas pockets within a gelatin sponge are uniform in size without discrete dominant bubbles. Gas droplets within an abscess, on the other hand, are more randomly arranged without size uniformity. Additionally, gelatin sponges become smaller on serial scans, and the gas droplets remain tightly packed and organized (40).

Mimics of Dissection

Graft Kink

A kinked aortic graft may occasionally mimic a short dissection flap on axial images, although the presence of a kink or fold is easily recognized on coronal and sagittal reformats (Fig 9). Because of the large size of aortic grafts, small kinks are generally not hemodynamically significant and do not progress to graft failure (41). Rare complications of severe graft kinking include a gradient across the kink, thrombus, or hemolytic anemia (42,43).

Figure 9a:

Figure 9a:

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(a) Axial contrast-enhanced CT image in a 52-year-old man after valve-sparing aortic root and ascending aorta repair shows an intraluminal linear filling defect mimicking an aortic dissection (arrow). (b) The coronal image confirms the line is due to a kinked graft (arrow).

Figure 9b:

Figure 9b:

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(a) Axial contrast-enhanced CT image in a 52-year-old man after valve-sparing aortic root and ascending aorta repair shows an intraluminal linear filling defect mimicking an aortic dissection (arrow). (b) The coronal image confirms the line is due to a kinked graft (arrow).

Elephant Trunk Procedure

The elephant trunk procedure is a two-stage approach in the repair of extensive thoracic aortic aneurysms (44). In the first stage, the proximal aorta (usually the ascending aorta and arch) is replaced by a graft with the distal portion—the “elephant trunk”—left suspended within the lumen of the descending thoracic aorta. This facilitates graft-to-graft anastomosis (open or endovascular) during the second stage by forgoing the need to cross-clamp the proximal segment of native aorta (45). Some surgeons also place radiopaque markers on the ends of the suspended graft to facilitate second stage endografting.

At imaging between the first and second stages, the elephant trunk can mimic a dissection in the proximal descending thoracic aorta (Fig 10). When the graft hangs in the center of the lumen, both sides of the graft can be seen and it is easily recognized as a tube rather than dissection. However, when the graft hangs eccentrically within the aorta and one side of the graft is indistinguishable from the wall of the native aorta, the other side is seen as a thin, linear filling defect mimicking a dissection. Thrombus occasionally forms between the elephant trunk and the native aorta, resembling thrombus within the false lumen of a dissected aorta. Potentially adding to the confusion, a residual dissection remains in the aorta more distally in patients whose aneurysms are the result of type B dissection.

Figure 10a:

Figure 10a:

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(a) Illustration of stage 1 of the elephant trunk procedure with ascending aorta and arch repair and the distal end of the graft suspended within the descending thoracic aorta (arrow). (Illustration courtesy of Marissa Craft Green.) (b–d) Images in a 69-year-old woman after stage 1 elephant trunk procedure for a type A aortic dissection and enlarging aneurysm. (b) A sagittal oblique contrast-enhanced CT image shows the elephant trunk suspended in the proximal descending thoracic aorta (white arrow) with a similar appearance as the residual dissection flap more distally (black arrows). (c) Axial and (d) coronal images depict the elephant trunk as a tube (arrows) rather than a dissection flap. (e) An axial contrast-enhanced CT image in a different patient shows an eccentric elephant trunk with one side of the graft mimicking a dissection flap (white arrows) and thrombus between the graft and native aorta mimicking false-lumen thrombus (black arrow).

Figure 10b:

Figure 10b:

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(a) Illustration of stage 1 of the elephant trunk procedure with ascending aorta and arch repair and the distal end of the graft suspended within the descending thoracic aorta (arrow). (Illustration courtesy of Marissa Craft Green.) (b–d) Images in a 69-year-old woman after stage 1 elephant trunk procedure for a type A aortic dissection and enlarging aneurysm. (b) A sagittal oblique contrast-enhanced CT image shows the elephant trunk suspended in the proximal descending thoracic aorta (white arrow) with a similar appearance as the residual dissection flap more distally (black arrows). (c) Axial and (d) coronal images depict the elephant trunk as a tube (arrows) rather than a dissection flap. (e) An axial contrast-enhanced CT image in a different patient shows an eccentric elephant trunk with one side of the graft mimicking a dissection flap (white arrows) and thrombus between the graft and native aorta mimicking false-lumen thrombus (black arrow).

Figure 10c:

Figure 10c:

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(a) Illustration of stage 1 of the elephant trunk procedure with ascending aorta and arch repair and the distal end of the graft suspended within the descending thoracic aorta (arrow). (Illustration courtesy of Marissa Craft Green.) (b–d) Images in a 69-year-old woman after stage 1 elephant trunk procedure for a type A aortic dissection and enlarging aneurysm. (b) A sagittal oblique contrast-enhanced CT image shows the elephant trunk suspended in the proximal descending thoracic aorta (white arrow) with a similar appearance as the residual dissection flap more distally (black arrows). (c) Axial and (d) coronal images depict the elephant trunk as a tube (arrows) rather than a dissection flap. (e) An axial contrast-enhanced CT image in a different patient shows an eccentric elephant trunk with one side of the graft mimicking a dissection flap (white arrows) and thrombus between the graft and native aorta mimicking false-lumen thrombus (black arrow).

Figure 10d:

Figure 10d:

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(a) Illustration of stage 1 of the elephant trunk procedure with ascending aorta and arch repair and the distal end of the graft suspended within the descending thoracic aorta (arrow). (Illustration courtesy of Marissa Craft Green.) (b–d) Images in a 69-year-old woman after stage 1 elephant trunk procedure for a type A aortic dissection and enlarging aneurysm. (b) A sagittal oblique contrast-enhanced CT image shows the elephant trunk suspended in the proximal descending thoracic aorta (white arrow) with a similar appearance as the residual dissection flap more distally (black arrows). (c) Axial and (d) coronal images depict the elephant trunk as a tube (arrows) rather than a dissection flap. (e) An axial contrast-enhanced CT image in a different patient shows an eccentric elephant trunk with one side of the graft mimicking a dissection flap (white arrows) and thrombus between the graft and native aorta mimicking false-lumen thrombus (black arrow).

Figure 10e:

Figure 10e:

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(a) Illustration of stage 1 of the elephant trunk procedure with ascending aorta and arch repair and the distal end of the graft suspended within the descending thoracic aorta (arrow). (Illustration courtesy of Marissa Craft Green.) (b–d) Images in a 69-year-old woman after stage 1 elephant trunk procedure for a type A aortic dissection and enlarging aneurysm. (b) A sagittal oblique contrast-enhanced CT image shows the elephant trunk suspended in the proximal descending thoracic aorta (white arrow) with a similar appearance as the residual dissection flap more distally (black arrows). (c) Axial and (d) coronal images depict the elephant trunk as a tube (arrows) rather than a dissection flap. (e) An axial contrast-enhanced CT image in a different patient shows an eccentric elephant trunk with one side of the graft mimicking a dissection flap (white arrows) and thrombus between the graft and native aorta mimicking false-lumen thrombus (black arrow).

Reverse Elephant Trunk Procedure

The reverse elephant trunk procedure is a similar staged approach to repair extensive thoracic aortic aneurysms. However, unlike in the conventional elephant trunk procedure, descending thoracic aorta repair is more pressing than for the more proximal segments. In the first stage, the elephant trunk is inverted and left suspended within the new descending thoracic aorta graft (46). It is then pulled proximally out of the graft to facilitate ascending aorta and arch repair during the second stage.

The imaging features between the first and second stages of the reverse elephant trunk procedure are similar to those of the conventional elephant trunk procedure. The elephant trunk is suspended within the proximal descending thoracic aorta, mimicking an aortic dissection (Fig 11). Thrombus also may form between the two grafts. Other modifications to the elephant trunk procedure, such as the frozen elephant trunk and buffalo trunk techniques, use stented endografts and therefore do not mimic aortic dissection (47).

Figure 11a:

Figure 11a:

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(a) Illustration of stage 1 of the reverse elephant trunk procedure with the elephant trunk suspended within the descending thoracic aorta graft (arrow). (Illustration courtesy of Marissa Craft Green.) (b, c) Images in a 76-year-old man after ascending aorta repair for type A aortic dissection who subsequently underwent stage 1 reverse elephant trunk procedure for an enlarging descending thoracic aorta aneurysm. (b) Sagittal oblique and (c) axial contrast-enhanced CT images show a short graft suspended in the proximal descending thoracic aorta graft, mimicking an aortic dissection (white arrows). Residual dissections are noted in the aortic arch and distal descending thoracic aorta (black arrows).

Figure 11b:

Figure 11b:

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(a) Illustration of stage 1 of the reverse elephant trunk procedure with the elephant trunk suspended within the descending thoracic aorta graft (arrow). (Illustration courtesy of Marissa Craft Green.) (b, c) Images in a 76-year-old man after ascending aorta repair for type A aortic dissection who subsequently underwent stage 1 reverse elephant trunk procedure for an enlarging descending thoracic aorta aneurysm. (b) Sagittal oblique and (c) axial contrast-enhanced CT images show a short graft suspended in the proximal descending thoracic aorta graft, mimicking an aortic dissection (white arrows). Residual dissections are noted in the aortic arch and distal descending thoracic aorta (black arrows).

Figure 11c:

Figure 11c:

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(a) Illustration of stage 1 of the reverse elephant trunk procedure with the elephant trunk suspended within the descending thoracic aorta graft (arrow). (Illustration courtesy of Marissa Craft Green.) (b, c) Images in a 76-year-old man after ascending aorta repair for type A aortic dissection who subsequently underwent stage 1 reverse elephant trunk procedure for an enlarging descending thoracic aorta aneurysm. (b) Sagittal oblique and (c) axial contrast-enhanced CT images show a short graft suspended in the proximal descending thoracic aorta graft, mimicking an aortic dissection (white arrows). Residual dissections are noted in the aortic arch and distal descending thoracic aorta (black arrows).

Cabrol Procedure

The original Cabrol procedure for ascending aorta repair has largely become obsolete with the ubiquity of the modified Bentall procedure. The modified Cabrol procedure is an important alternative when severe calcification of the ascending aorta or coronary arteries limits the ability to mobilize and reattach the coronary arteries (48). In the modern Cabrol procedure, the ascending aorta is replaced with an interposition graft and additional smaller interposition grafts to the coronary arteries are anastomosed to the ascending aorta graft. These coronary grafts may be attached to the aorta as a single coronary artery by a side-to-side anastomosis (hemi-Cabrol), as separate arteries by end-to-side anastomoses, or in T-fashion.

Because attaching the left main coronary artery to the anterior aspect of the aorta graft is technically more feasible than attaching it at its more anatomic position posteriorly, the new coronary artery takes a retroaortic course at imaging. It also tends to run closely alongside the aorta graft, and the two graft walls together resemble a linear intraluminal filling defect, mimicking an aortic root dissection with the aorta and coronary conduit as the two lumens (49) (Fig 12). ECG gating improves evaluation of this region and helps distinguish between the two.

Figure 12a:

Figure 12a:

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Images in a 66-year-old man after Cabrol procedure for ascending aorta repair. (a) Axial contrast-enhanced maximum intensity projection CT image shows a retroaortic left main coronary artery conduit (white arrow) attached to the anterior wall of the ascending aorta graft. The closely apposed walls of the ascending aorta graft and coronary conduit mimic an aortic dissection (black arrow). (b) A three-dimensional volume-rendered reconstruction image shows the coronary conduit arising from the anterior side of the aortic graft (white arrow), coursing along the aorta, and anastomosing to the native left main coronary artery (black arrow).

Figure 12b:

Figure 12b:

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Images in a 66-year-old man after Cabrol procedure for ascending aorta repair. (a) Axial contrast-enhanced maximum intensity projection CT image shows a retroaortic left main coronary artery conduit (white arrow) attached to the anterior wall of the ascending aorta graft. The closely apposed walls of the ascending aorta graft and coronary conduit mimic an aortic dissection (black arrow). (b) A three-dimensional volume-rendered reconstruction image shows the coronary conduit arising from the anterior side of the aortic graft (white arrow), coursing along the aorta, and anastomosing to the native left main coronary artery (black arrow).

Conclusion

Various surgical techniques of the aorta result in expected imaging appearances that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. While identifying these complications is of obvious importance, recognizing a complication mimic can prevent unnecessary communication to the surgeon, follow-up imaging, or surgical revision. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of mimics are essential for accurate interpretation.

Optimal imaging protocols are essential in characterizing complications and their mimics. By differentiating surgical material from extraluminal contrast material or peripheral hyperattenuation from rim enhancement, precontrast imaging can help exclude a pseudoaneurysm or abscess. ECG gating improves aortic root evaluation and can help distinguish a coronary button from a pseudoaneurysm or a coronary conduit after Cabrol procedure from a dissection. For particularly challenging cases, operative notes and additional information in the medical record may clarify any unfamiliar or unusual imaging findings. In situations of continued uncertainty over the presence of a complication, communicating with the surgeon directly is the surest way of understanding the findings and delivering important results.

Acknowledgments

Acknowledgment

We would like to thank Marissa Green for providing illustrations.

Disclosures of Conflicts of Interest: D.B.G. disclosed no relevant relationships. D.B.V. disclosed no relevant relationships. T.B.R. disclosed no relevant relationships. C.A.R. disclosed no relevant relationships. W.R.J. disclosed no relevant relationships. Q.A.T. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: institution received research grant from Ziosoft. Other relationships: disclosed no relevant relationships.

Abbreviation:

ECG
electrocardiography

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