Clinical profile of post-operative ductal aneurysm and usefulness of sternotomy and circulatory arrest for its repair

Abstract

Objective: Post-operative ductal aneurysm is a rare but fatal condition. We retrospectively analyzed the clinical profile of post-operative ductal aneurysm and outcome of their repair with different surgical approaches.

Methods: From January 1976 to December 2002, 13 patients underwent repair of post-operative ductal aneurysm. The case data of the patients operated were analyzed and survivors were followed-up. Three patients underwent repair through left thoracotomy, femoro-femoral bypass and 10 patients underwent patch aortoplasty through sternotomy using total circulatory arrest with minimal dissection. Among the sternotomy group, nine patients had midline sternotomy and one patient had transverse sternotomy with the patient in semi-right-lateral position. Hemoptysis (69%) was the commonest presenting symptom. Ten patients had ligation and three patients had division of ductus. Mean age at ductus interruption was 13.7+/-8.2 years; mean time interval for development of aneurysm was 3.6+/-4.2 years; mean age at aneurysm surgery was 16.9+/-8.8 years. Residual left to right shunt was detected in 6 (46%) patients.

Results: Three patients repaired through left thoracotomy with femoro-femoral bypass died during surgery due to rupture of aneurysm during dissection and profuse bleeding. Thirty-day survival in patients operated through sternotomy using circulatory arrest was 90% (9/10). Two patients required additional incision in second left intercostal space along with midline sternotomy, for access to descending thoracic aorta. Of these two patients, one patient had bleeding from friable aorta and died; another patient developed left hemiplegia; circulatory arrest time was prolonged in this patient. Mean follow-up period was 9.6+/-5.3 years. Persistent left vocal cord palsy was seen in one patient. One patient was lost to follow-up after 3-years. Remaining eight patients were asymptomatic at follow-up.

Conclusion: Repair of postoperative ductal aneurysm through left thoracotomy is difficult due to extreme fragility of aneurysm and because of reoperative difficulties. The immediate and long-term outcome of the cases operated through sternotomy using total circulatory arrest with minimal dissection is good. Midline sternotomy limits approach to descending thoracic aorta that can be circumvented by using transverse sternotomy with semi-right-lateral positioning of the patient.