PMC8581774_01
(a) Pre-operative CT-angiogram sagittal-section showing severe narrowing of the extra-anatomic aortic graft (white arrow) and native aorta (yellow arrow). (b) Pre-operative 3D volume rendered image showing a pseudoaneurysm at the proximal anastomosis of the graft.
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The extra-anatomical graft was occluded for 7.5 cm with a residual patent lumen measuring 3-4 mm in diameter just above the distal anastomosis (Figure 1(a) and (b)).
Intra-operative findings. (a) On table extra-anatomic graft showing tubular calcification. (b) Post-operative replacement with a Dacron graft. (c) Excised extra-anatomical graft. (d) Pseudo-aneurysm at the proximal anastomosis measuring 4 cm.
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Intra-operative findings showed compression of the right ventricle by the extra-anatomical graft (Figure 2(a)). Re-anastomosis was performed using a 22-mm Hemashield (Maquet-Getinge, Rastatt, Germany) graft with the proximal anastomosis re-done to the ascending aorta and distal anastomosis to the stump of the native graft above the infrarenal abdominal aorta (Figure 2(b)) using continuous 4-0 polypropylene sutures. On inspection of the excised graft, there was a large pseudoaneurysm around the proximal end (Figure 2(c) and (d)).
(a) Cut section of the extra-anatomical graft showing extensive dystrophic calcification and organized thrombus. (b) Inner surface of extra-anatomical graft showing lumen filled with thrombosed blood (white arrow). Outer tubular capsule surrounding graft showing calcification (yellow arrow). (c) Histopathological slide of the tissue surrounding the excised graft showing hyalinization and calcification. (d) Schematic representation of the extra-anatomical graft explaining the mechanism of occlusion. Proximal anastomosis dehiscence leading to the formation of a pseudoaneurysm filled with thrombotic content causing increased pressure in the surrounding tubular capsule of the graft (black arrow) and dystrophic calcification.
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The tubular capsule of tissue around the graft was calcified, and the graft was extrinsically compressed by the calcified thrombotic content (Figure 3(a)). Inner surface of extra-anatomical graft showed ulcerations and a lumen filled with thrombosed blood (Figure 3(b)). Histopathological examination of the graft specimen showed hyalinization of the vessel wall with chunks of calcification (Figure 3(c)).