Thoracic aorta false aneurysm: what surgical strategy should be recommended?

BACKGROUND: Thoracic aorta false aneurysms (TAFA) are a surgical challenge. The best technical approach remains uncertain. METHODS: Between 1981 and 2004, 57 patients underwent operation for TAFA (mean age 57 +/- 18 years; 43 [75%] were male). Symptoms included dyspnea 25 (44%), chest pain 22 (39%), and fever 18 (32%). Twelve (21%) were asymptomatic. Thirty-seven (65%) had undergone previous operation with a mean interval between operations of 80 +/- 90 months. Fifteen (26%) had a mycotic etiology. The TAFA involved the aortic root in 10 (18%), ascending aorta in 28 (49%), arch in 6 (11%), and descending aorta in 13 (32%). Twenty-one (37%) required femorofemoral cannulation and 28 (49%), circulatory arrest. Surgical techniques included graft replacement in 27 (47%), composite root in 10 (18%), patch repair in 10 (18%), and direct suture in 10 (18%). RESULTS: Operative mortality was 7% (4 patients). Four of 32 (13%) had massive hemorrhage during redo sternotomy, and all of these had planned extramediastinal cannulation (all survived). Follow-up was 100% for 349 patient-years. Actuarial survival was 77% +/- 6%, 63% +/- 8%, and freedom from recurrent TAFA was 87% +/- 5% and 83% +/- 7%, at 5 and 10 years, respectively. Univariate analysis identified TAFA greater than 55 mm, urgent operation, and NewYork Heart Association functional class III or IV as predictors of hemorrhage during redo sternotomy. Obesity and ejection fraction of 35% or less were predictors of operative death. CONCLUSIONS: Thoracic aorta false aneurysm symptoms may be minimal, and consequently a high degree of suspicion plus serial imaging is warranted. Extramediastinal cannulation, deep hypothermia, and circulatory arrest are required for large mediastinal TAFA. Despite serious risks, TAFA correction is possible with good long-term results.