Coronary pseudoaneurysm after Bentall-Bono intervention: A novel treatment to a rare surgery complication

Abstract

We present a rare case of a coronary pseudoaneurysm after a Bentall-Bono procedure. During a routine follow-up computed tomography scan, a pseudoaneurysm located between the aorta and the proximal portion of the right coronary artery was diagnosed. Contrast extravasation was observed with partial thrombosis of the pseudoaneurysm. Coronary angiography and intravascular ultrasound were performed showing the point of contrast extravasation dependent of the right coronary artery in its proximal portion. An angioplasty procedure was performed sealing the pseudoaneurysm with the implantation of a covered stent. After an uneventful postoperative follow-up, the patient was discharged home.

Learning objective

The development of a coronary artery pseudoaneurysm (CAP) after complex cardiac surgeries, like Bentall-Bono procedure, could be a life-threatening condition. The possible derived complications of CAP are rupture, compression of surrounding structures, or coronary ischemia.

Although surgical approach to a CAP may have an extremely high surgical risk, most of the cases require a complex surgical repair. We describe a novel possible treatment option by angioplasty and sealing of the CAP with the implantation of a covered stent.

Introduction

Coronary artery aneurysm (CAA) is a rare condition described as a coronary artery dilation; the most frequent etiology is atherosclerosis followed by Kawasaki disease. Iatrogenic wall injury, inflammatory arterial diseases, endocarditis, and connective tissue disorders are other possible causes [1]. Whereas coronary artery pseudoaneurysm (CAP) is a challenging complication secondary to weak tissue in the coronary wall which could be caused by aortic dissection, connective tissue diseases, or surgical technical failure during ostial reimplantation.

After a Bentall-Bono surgery, CAP of the reimplanted ostium is an infrequent but worldwide reported complication, whereas true ostial CAA has only been described in cases of Marfan syndromes [2]. The development of CAP after surgery has also been attributed to an intrinsic weakness of the aortic wall or an excess of tension developing on the suture line caused by blood under pressure accumulating within the aortic wrap, persistent bleeding into the perigraft space, and graft infection [3,4].

We present a case in which a computed tomography (CT) scan showed contrast extravasation after a Bentall-Bono procedure depending on the right coronary artery (RCA) corresponding to a CAP.

Case report

A 53-year-old male with a history of hypertension, human immunodeficiency virus infection, and chronic renal failure underwent a Bentall-Bono procedure due to aortic valve insufficiency and aortic root aneurysm. The patient had no physical features of Marfan syndrome or any other connective tissue disease. The surgery was uneventful, and the patient was discharged home 10 days after surgery.

Six months after the surgery, an image that suggested a partially thrombosed CAP adjacent to the 23 mm composite graft (St. Jude Medical, St Paul, MN, USA) was observed in a routine echocardiography. The patient had normal cardiac chambers, preserved ventricular function, and absence of valvular diseases.

A CT scan was requested, showing contrast extravasation in the proximal part of the RCA, creating a cavity of approximately 2 cm in diameter. The first suspected entity was a CAP of the reimplanted RCA ostium in the composite graft, however, the exact point of contrast extravasation was not identified in the CT scan. The patient was asymptomatic, for that reason an initial blood pressure control and close follow-up were performed.

A second CT scan was scheduled one month later confirming the presence of active bleeding CAP with peripheral thrombus that had increased in size compared to the previous scan (Fig. 1). The CAP apparently depended on the proximal portion of the RCA.

Fig. 1.

Angio computed tomography scan showing coronary artery pseudoaneurysm (red arrow) depending on right coronary artery. Axial cut (left) and 3D reconstruction (right).

The case was debated by a multidisciplinary team between cardiac surgeons and cardiologists and a percutaneous procedure was decided as the best option. A coronarography was scheduled in which a CAP dependent on the proximal segment of RCA was confirmed by coronarography (Fig. 2a) and verified by intravascular ultrasound (IVUS) (Fig. 3). RCA had no significant lesions and a vessel size of 3.9 × 4 mm. A 3.5 × 15 covered stent (PK Papyrus^R, Biotronik, Berlin, Germany) was implanted. Control angiography was performed, confirming the sealing of the CAP without contrast extravasation (Fig. 2b). In addition, intra-stent area greater than 10 mm² was verified by IVUS. The procedure was uneventful, and the patient was discharged home under anticoagulant treatment. A control CT was performed four months later, and no CAP was identified (Fig. 4).

Fig. 2.

Coronary angiography showing a narrow neck coronary artery pseudoaneurysm (CAP) (red arrow) depending on the proximal segment of right coronary artery with contrast extravasation (a) and the posterior sealing of the CAP after the stent placement (b).

Fig. 3.

Intravascular ultrasound showing the neck of the coronary artery pseudoaneurysm (red arrow).

Fig. 4.

Control angio computed tomography scan: Axial cut (left) and 3D reconstruction (right) of the right coronary artery location showing the complete disappearance of the coronary artery pseudoaneurysm.

Discussion

CAPs and CAAs have been reported after aortic root surgery [3,[5], [6], [7]], however, they are mainly located at the level of the ostial anastomosis and treated by surgical approach. We report here a patient with a CAP after a Bentall-Bono procedure who successfully underwent a coronary angioplasty with a covered stent.

Although there are no specific guidelines to manage CAPs or CAAs, the risk of possible complications such as rupture, enlargement, compression of surrounding structures, or coronary lesions must be considered [1]. The balance between the reoperation surgical risk and the risk of these complications must be taken into account and individualized. Although the surgical risk may be high, the majority of cases require surgical repair [6]. After a literature review, the types of surgical techniques described are widely variable [3] some studies have mentioned a simple suture repair while others followed complicated aortic root reconstructions such as a Cabrol–II “moustache” technique [8], coronary revascularization [9], or complete replacement of the graft with direct implantation of coronary buttons [4]. As far as we are concerned, no less aggressive procedures were performed in the treatment of CAPs. We found only one other case in which authors reported a giant CAA involving the circumflex coronary artery 10 years after a Bentall-Bono procedure, in that case, the CAA was assumed not to be correlated with the previous surgical procedure and it was treated conservatively [5].

To our knowledge, this is the first case reporting a CAP after a Bentall procedure treated with angioplasty, in which the collaborative work between specialties resulted to be successful.

Declaration of competing interest

None.