CTICasesAorto-Pulmonary Artery Fistula and Pseudoaneurysm at Aortic Graft Anastomosis
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Imaging findings
Initial imaging following type A aortic dissection repair with an ascending aortic graft shows expected post-surgical changes. Subsequent CT reveals extravasation of contrast medium near the proximal anastomosis of the aortic root, indicating a pseudoaneurysm. There is also fresh blood accumulating in the mediastinum. An intriguing small attenuating object, possibly a suture, and an adjacent filling defect near the pulmonary artery are noted. Follow-up CT demonstrates progression with clear contrast extravasation from both proximal and presumed distal aortic anastomoses, and dramatic filling defects within the main pulmonary artery and its branches, consistent with organized thrombus and an aortopulmonary fistula. The point of entry into the pulmonary artery appears to be near the initial small object and filling defect.
Key takeaways
Complications of aortic graft repair, such as pseudoaneurysm formation and graft dehiscence, can occur. These can be exacerbated or precipitated by subclinical infection. A rare but severe complication is the formation of an aortopulmonary artery fistula, where a communication develops between the aorta/graft and the pulmonary artery, leading to blood shunting and formation of thrombus within the pulmonary artery lumen. These cases carry high morbidity and mortality, often requiring complex re-operations. Surgeons may sometimes elect to observe pseudoaneurysms due to the complexities of re-operation in previously dissected and repaired aortas, especially given the extensive adhesions from prior sternotomy.
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