Hemolytic Anemia Occurring 14 Years after Ascending Aortic Replacement for Acute Type A Aortic Dissection Due to Aortic Pseudoaneurysm Derived from Anastomotic Leakage: A Case Report

Abstract

A 64-year-old male patient who presented with symptoms indicative of hemolytic anemia was referred to our hospital. After obtaining the patient's history, it was found that hemolysis occurred 14 years after he underwent ascending aortic replacement for acute type A aortic dissection. Enhanced computed tomography revealed an aortic pseudoaneurysm at the proximal anastomosis, which was thought to be the cause of hemolysis. Furthermore, aortic valve regurgitation and dilatation of the sinus of Valsalva were also found on a transthoracic echocardiogram. Therefore, the Bentall procedure was performed. During the surgery, aortic pseudoaneurysm formation and vascular graft stenosis were observed. The postoperative course was uneventful, and hemolysis diminished soon after the surgery.

Keywords: acute aortic dissection; aortic pseudoaneurysm; hemolytic anemia.

Fig. 1 Preoperative computed tomography and transthoracic echocardiogram findings. (A) Coronal image of the ascending aorta. The white and black arrowheads indicate intact and detached aortic grafts, respectively. The white arrows indicate the wall of the pseudoaneurysm, and the black arrow indicates the detached proximal anastomotic site. (B) A horizontal image of the ascending aorta. The true lumen of the aortic graft (a) is compressed by the pseudoaneurysm (b). (C) An apical three-chamber view showing moderate aortic regurgitation. (D) A parasternal long-axis view showing dilatation of the sinus of Valsalva.

Fig. 2 Intraoperative findings at the proximal anastomotic site and transesophageal echocardiogram findings. (A) The white arrows indicate the pseudoaneurysm wall, and the black arrows and arrowheads represent the intact and detached aortic grafts, respectively. (B) A mid-esophageal short-axis view of the ascending aorta shows blood flow from the aortic graft (a) to the pseudoaneurysm (b). (C) A mid-esophageal long-axis view showing dilatation of the sinus of Valsalva and the aortic annulus. (a) and (b) indicate the aortic graft and the pseudoaneurysm, respectively.

Fig. 3 Postoperative findings of laboratory results and three-dimensional computed tomography (CT). (A) Laboratory results showing the improvement of hemolytic anemia and renal dysfunction. (B) A three-dimensional image of an enhanced CT. The anastomotic sites are intact. There is no evidence of a pseudoaneurysm (black arrows), and both the new and old grafts show sufficient expansion.