APW is a congenital heart disease with traffic between the ascending aorta and pulmonary artery, accounting for 0.2% of all the congenital heart diseases [1]. APW leads to pulmonary hypertension and Eisenmenger syndrome without early surgery, and surgical repair is not possible [2]. In the present case, the patient was 5 years old at the time of APW diagnosis, leading to Eisenmenger syndrome; therefore, surgery was not indicated. At 19 years of age, the patient started treatment for pulmonary hypertension with pulmonary vasodilators. The patient was then registered for lung transplantation, and APW repair was planned at the time of lung transplantation.
Although a case of APW with ascending aortic aneurysm complications has been reported [3], to our knowledge, this is the first report of a pseudoaneurysm at the anastomotic site after APW repair.
In the present case, the aortopulmonary artery traffic area was dissected on the pulmonary artery side and closed directly between the aortic sides with strips of felts.
The reasons for choosing this procedure instead of graft replacement of the ascending aorta are described below.
The short- and long-term postoperative results of a simple APW correction in childhood are excellent, and the occurrence of postoperative pseudoaneurysm has not been reported [2,4-6].
Wound healing is delayed, and the patient is prone to infection due to the use of immunosuppressive drugs and steroids after bilateral lung transplantation. In addition, graft replacement of the ascending aorta is more invasive because it involves cardiac and circulatory arrest.
For these reasons, we decided that a direct closure, a less invasive procedure without artificial blood vessel , was appropriate.
However, this resulted in an anastomotic pseudoaneurysm at the direct closure site.
Common causes of anastomotic pseudoaneurysms include arterial wall degeneration, arterial fragility, suture failure, infection, and anastomotic technique [7].
The causes of the pseudoaneurysm in the present case may have been: 1) a failure to match the intima of blood vessels to each other at the time of direct closure on the aortic side during APW repair.
2) using steroids and immunosuppressive drugs after lung transplantation may have caused delayed wound healing at the direct closure on the aortic side.
In the present case, CT showed no pseudoaneurysm eight months after the procedure, and a pseudoaneurysm was first observed nine months after the procedure.
Since it was not a pseudoaneurysm in the acute postoperative period, it was more likely due to delayed wound healing caused by postoperative steroids and immunosuppressive medications than the anastomotic technique.
To conclude, we have experienced a case of a pseudoaneurysm at the anastomotic site after APW repair and bilateral lung transplantation.
The choice of surgical technique should be based on the patient’s background requiring lung transplantation, and close postoperative follow-up is required.