Large Pulmonary Artery Aneurysm Replacement with Vascular Prothesis in a Patient with Coronary Artery Disease and PFO

This video presents the management of a complex and infrequently encountered scenario. A sixty-nine-year-old patient had a large pulmonary artery aneurysm extending from the main pulmonary artery (PA) up to the bifurcation with further extension into the left PA and relative sparing of the right. The patient had a history of a heart murmur and was found to have mild pulmonary vein stenosis, which has been stable since the age of twenty-two. 

The patient presented with exertional chest pain and a workup revealed chronic total occlusion of the left anterior descending (LAD) and right coronary arteries. Furthermore, a patent foramen ovale (PFO) was found on the patient’s echocardiogram. His pulmonary artery aneurysm was seen to have enlarged by 0.2 cm over the previous year, now measuring 5.6 x 5.8 cm. The patient did not have any significant pulmonary artery hypertension. After evaluation in clinic and discussion with the patient, the surgical team elected to proceed with operative management of all three pathologies.

The Surgery

First, the patient underwent a median sternotomy, and a pedicelled left internal mammary artery (LIMA) was harvested endoscopically, along with the saphenous vein. Surgeons opted for bicaval and direct aortic cannulation with antegrade cardioplegic arrest. PFO repair was performed initially to prevent any air entraining from the right side into the left throughout the remainder of the case. 
After that, the pulmonary artery was opened and analyzed, along with the pulmonary valve. The valve appeared thickened, but the leaflets were pliable and compliant without evidence of significant stenosis, so its replacement was not necessary. There were several possible configurations for reconstruction of the PA and, based on this patient’s anatomy, it seemed most appropriate to reconstruct it in a T-tube fashion with a single graft bridging the left to the right PA branches and a separate woven graft from the main PA joining the branched PA graft. Once the graft reconstruction was complete and suture lines were thoroughly inspected, the coronary revascularization ensued with a vein graft off the aorta to the posterior descending coronary artery and LIMA-to-LAD anastomoses. 

Finally, the patient was successfully weaned from bypass. He had an uneventful course of recovery, and postoperative imaging showed stable repair of PA along with resolution of his exertional chest pain.

References

1. Kreibich, Maximilian, et al. "Aneurysms of the pulmonary artery." Circulation 131.3 (2015): 310-316.

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