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\begin{document}

\title{Precise Endoballoon Positioning for High-Risk Sternal Re-Entry in an
Ascending Aortic Pseudoaneurysm with Patent Coronary Grafts}



\author[1]{Katie E. O’ Sullivan}%
\author[2]{Anand Mehta}%
\author[1]{Patrick Vargo}%
\affil[1]{Cleveland Clinic Department of Thoracic and Cardiovascular Surgery}%
\affil[2]{Cleveland Clinic}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Redo cardiac surgery can present a unique set of challenges even to the
experienced surgeon. Although outcomes have steadily improved in the
modern era; if an intraoperative adverse event occurs, there is a 5\%
incidence of mortality and 19\% incidence of myocardial infarction,
stroke or death {[}(1){]}(\#ref-0001). Overall, the modern incidence of
mortality at reoperation varies but be segregated into low and higher
risk cohorts depending on the planning computed tomography imaging and
risk to substernal structures on re-entry {[}(2, 3){]}(\#ref-0002).
Patients with ascending aortic or root pseudoaneurysms represent a
particularly difficult subset of high-risk patients requiring
re-operative cardiac surgery due to the danger of exsanguination and air
embolization {[}(4){]}(\#ref-0004). Some surgeons advocate the use of
deep hypothermic circulatory arrest (DHCA) to achieve safe re-entry in
such cases however this can result in unpredictable DHCA duration
depending on the degree of pericardial adhesions {[}(5){]}(\#ref-0005).
We report a case of aortic pseudoaneurysm in a patient with patent
coronary grafts managed using an endoballoon precisely positioned
relative to the proximal anastomoses resulting in a safe surgical
re-entry and shorter DHCA time.%
\end{abstract}%



\sloppy


\textbf{Precise Endoballoon Positioning for High-Risk Sternal Re-Entry
in an Ascending Aortic Pseudoaneurysm with Patent Coronary Grafts}

Katie E. O' Sullivan\textsuperscript{1}, Anand R.
Mehta\textsuperscript{2}, Patrick R. Vargo\textsuperscript{1}

\textsuperscript{1} Departments of Thoracic and Cardiovascular Surgery,
The Cleveland Clinic, Ohio

\textsuperscript{2} Department of Cardiothoracic Anesthesiology, The
Cleveland Clinic, Ohio

\textbf{Address for correspondence:}

K.E. O' Sullivan,

The Cleveland Clinic,

9500 Euclid Avenue,

Cleveland,

OH 44195

Tel: +1 216 444-2200

E-mail: osullik@ccf.org

\emph{Abstract}

Redo cardiac surgery can present a unique set of challenges even to the
experienced surgeon. Although outcomes have steadily improved in the
modern era; if an intraoperative adverse event occurs, there is a 5\%
incidence of mortality and 19\% incidence of myocardial infarction,
stroke or death (1). Overall, the modern incidence of mortality at
reoperation varies but be segregated into low and higher risk cohorts
depending on the planning computed tomography imaging and risk to
substernal structures on re-entry (2, 3). Patients with ascending aortic
or root pseudoaneurysms represent a particularly difficult subset of
high-risk patients requiring re-operative cardiac surgery due to the
danger of exsanguination and air embolization (4). Some surgeons
advocate the use of deep hypothermic circulatory arrest (DHCA) to
achieve safe re-entry in such cases however this can result in
unpredictable DHCA duration depending on the degree of pericardial
adhesions (5). We report a case of aortic pseudoaneurysm in a patient
with patent coronary grafts managed using an endoballoon precisely
positioned relative to the proximal anastomoses resulting in a safe
surgical re-entry and shorter DHCA time.

\emph{Case Description}

A 52-year-old gentleman, with several cardiovascular risk factors was
referred for surgical management; other history was notable for end
stage renal disease with a left upper limb fistula, severe peripheral
vascular disease, and Protein C deficiency resulting in recurrent deep
vein thrombosis requiring a greenfield filter. He had undergone coronary
artery bypass grafting five months prior with LIMA-LAD, and saphenous
vein grafts to posterior descending artery and ramus intermedius
complicated by left arm ischemia requiring angioplasty. He had
re-presented at an interval with progressive dizziness, fatigue, and
lightheadedness. Computed tomography (CT) imaging revealed an aortic
pseudoaneurysm at the original aortic cannulation site with an ostium of
9 x 7 mm that was compressing 50\% of the main pulmonary artery (figure
1A).

\textbf{Hosted file}

\verb`image1.emf`  available at \url{https://authorea.com/users/488856/articles/572825-precise-endoballoon-positioning-for-high-risk-sternal-re-entry-in-an-ascending-aortic-pseudoaneurysm-with-patent-coronary-grafts}

\textbf{Figure 1.} A) 3D CT reconstruction demonstrating the aortic
pseudoaneurysm when initially diagnosed in communication with the former
aortic cannulation site. B) A further 3D CT reconstruction demonstrates
enlargement of the pseudoaneurysm observed twelve days later with
interval re-imaging

In addition to his remaining workup, an interval CT twelve days later
demonstrated an increase in the size of the pseudoaneurysm and
surrounding complex fluid collection in the anterior mediastinum.
Infectious etiology could not be out-ruled (Figure 1B, Figure 2).

\textbf{Hosted file}

\verb`image2.emf`  available at \url{https://authorea.com/users/488856/articles/572825-precise-endoballoon-positioning-for-high-risk-sternal-re-entry-in-an-ascending-aortic-pseudoaneurysm-with-patent-coronary-grafts}

\textbf{Figure 2.} A) Sagittal section demonstrating the enlarging
aortic pseudoaneurysm. Of note is the relationship of the pseudoaneurysm
neck in relation to the right main pulmonary artery on this image. This
relationship was used as an anatomical landmark; constant between CT and
TEE imaging for planning the position of the endoballoon
intraoperatively relative to the patent coronary grafts more proximally
which was critical to successful endoballoon placement B) Axial CT
images showing the proximity of the pseudoaneurysm to the posterior
sternal table highlighting the risk of rupture upon re-entry.

Surgery was carried out using right axillary cannulation with a Y to the
right common femoral artery. A venous access cannula was placed in the
right femoral vein. An endoballoon was advanced from the left femoral
artery to the distal ascending aorta just distal to the aortocoronary
grafts using a combination of fluoroscopy and TEE (Figure 3).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3} A) TEE image demonstrating preoperative aortic
pseudoaneurysm along the anterior aspect of the ascending aorta, the
right main pulmonary artery was utilized as a landmark for endoballoon
positioning safely above the patent proximal coronary anastomoses B)
Intraoperative image demonstrating the inflated endoballoon in situ
above the patent grafts while cardioplegia was being delivered to the
aortic root.

A percutaneous retrograde cardioplegia catheter was advanced under TEE
guidance into the coronary sinus. Cardiopulmonary bypass was commenced
and upon re-sternotomy bleeding was encountered from the pseudoaneurysm.
The endoballoon was inflated above the proximal coronary anastomoses to
occlude the aorta and control the bleeding. The endoballoon also served
to deliver antegrade cardioplegia. In view of the patent LIMA-LAD graft,
continuous retrograde cardioplegia and systemic hyperkalemia also
instituted and cardioplegic arrest was achieved; during this period the
endoballoon served as a vent. Further dissection was carried out
revealing a 1cm defect in the distal ascending aorta at the previous
cannulation site (Figure 4).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{Figure 4} A,B) these intraoperative images demonstrate the 1cm
defect in the ascending aorta, shown at the tip of the forceps, which
was subsequently repaired

Once the patient was adequately cooled, DHCA was instituted and the
endoballoon deflated. A bovine pericardial patch was sewn into the
defect, the aorta and heart de-aired, systemic flow restored, and the
patient rewarmed. Endoballoon inflation time was 32 minutes with DHCA of
only 8 minutes. Post procedural echo demonstrated normal biventricular
function and the patient was transferred to intensive care in a stable
condition. Post procedural CT demonstrated an excellent result with
complete resolution of the pseudoaneurysm (figure 3).

\textbf{Hosted file}

\verb`image5.emf`  available at \url{https://authorea.com/users/488856/articles/572825-precise-endoballoon-positioning-for-high-risk-sternal-re-entry-in-an-ascending-aortic-pseudoaneurysm-with-patent-coronary-grafts}

\textbf{Figure 5.} Computed Tomography images two days postoperatively
demonstrating a normal aortic contour with resolution of the aortic
pseudoaneurysm.

\emph{Comment}

The development of minimally invasive mitral surgical approaches and the
concomitant anesthetic upskilling that has been required has resulted in
a broader range of tools at the disposal of cardiac surgical teams
approaching cases such as these. Advantages of using the endoballoon in
this setting are shorter DHCA time, excellent myocardial protection and
complete decompression of the left ventricle during re-entry. Whilst
this approach has been reported in several other publications, this case
is unique due to the added complication of patent coronary grafts (4).
Pre-procedural CT imaging was utilized to identify an anatomical
landmark which could be used on TEE to position the endoballoon relative
to the patent grafts. The approach facilitated an excellent recovery.
Knowledge of the balloon length is critical for precise placement and
identification of a `landing zone' during cases with patent proximal
coronary anastomoses. We believe the endoballoon strategy is easily
replicated in centers with an active minimally invasive cardiac surgical
program.

\emph{References}

1. Roselli EE, Pettersson GB, Blackstone EH, Brizzio ME, Houghtaling PL,
Hauck R, et al. Adverse events during reoperative cardiac surgery:
frequency, characterization, and rescue. J Thorac Cardiovasc Surg.
2008;135(2):316-23, 23 e1-6.

2. Kindzelski BA, Bakaeen FG, Tong MZ, Roselli EE, Soltesz EG, Johnston
DR, et al. Modern practice and outcomes of reoperative cardiac surgery.
J Thorac Cardiovasc Surg. 2021.

3. Keeling WB, Leshnower BG, Thourani VH, Kilgo PS, Chen EP. Outcomes
following redo sternotomy for aortic surgery. Interact Cardiovasc Thorac
Surg. 2012;15(1):63-8.

4. Li K, Ayoub C, Pettersson G, Rodriguez L, Mehta AR. Multimodality
Imaging in the Evaluation of Ascending Aortic Pseudoaneurysms to Guide
Complex Surgical Management. CASE (Phila). 2020;4(5):433-8.

5. Dumont E, Carrier M, Cartier R, Pellerin M, Poirier N, Bouchard D, et
al. Repair of aortic false aneurysm using deep hypothermia and
circulatory arrest. Ann Thorac Surg. 2004;78(1):117-20; discussion 20-1.

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