Surgical Management of Giant Pulmonary Artery Aneurysm Using a T-Shaped Graft-Valve Strategy

A 56-year-old woman with no significant past medical history presented with progressive dyspnea on exertion and intermittent back pain. Computed tomography (CT) of the chest demonstrated a markedly dilated main pulmonary artery measuring 7 x 6 cm, consistent with a giant pulmonary artery aneurysm. Transesophageal echocardiography confirmed severe aneurysmal dilation of the pulmonary artery, severe pulmonary insufficiency, and a significantly dilated right ventricle with preserved systolic function. A patent foramen ovale was also identified. Given the patient’s symptoms, right sided chamber remodeling, valvular insufficiency, and aneurysm size, operative intervention was recommended.

Surgical Techniques

Preparation

The patient was positioned supine and underwent median sternotomy. Systemic heparinization was achieved, and cardiopulmonary bypass was initiated via peripheral cannulation of the right common femoral artery and vein, with additional superior vena cava cannulation.

Exposition

After institution of bypass, the markedly enlarged right ventricular outflow tract, main pulmonary artery, and branch pulmonary arteries were carefully exposed. Meticulous dissection was performed to separate the pulmonary artery from the ascending aorta and to mobilize both the right and left main pulmonary arteries to allow for tension-free reconstruction.

Operation

After aortic cross-clamping, antegrade and retrograde cardioplegia were administered. A longitudinal arteriotomy of the main pulmonary artery revealed an abnormal pulmonic valve. One of the leaflets was essentially nonexistent, and the remaining two were excised. The right main pulmonary artery was transected just proximal to the superior vena cava and a 22 mm Hemashield graft was anastomosed end-to-end using running 5-0 Prolene. The graft was sewn within the pulmonary artery lumen, preserving a native cuff for potential hemostasis. The graft was tunneled beneath the aorta toward the left main pulmonary artery. The graft was beveled to accommodate the larger left pulmonary artery, where a second end-to-end anastomosis was performed using 5-0 Prolene.

The pulmonary valve annulus was sized and noted to accommodate a 29 mm Konect Resilia Valve Conduit. The valve was secured below the annulus posteriorly and anteriorly at the annulus using 4-0 Prolene, creating a subtle posterior tilt to prevent conduit kinking. A side opening was created in the graft, and the distal end of the valved conduit was tailored and anastomosed to this opening using 5-0 Prolene, forming a T-shaped graft-valve configuration. Subsequently, the superior vena cava and inferior vena cava were snared, and a right atriotomy was created. The large patent foramen ovale was closed in two layers using 5-0 Prolene.

Completion

After thorough deairing in the Trendelenburg position, the aortic cross-clamp was removed. Following confirmation of adequate valve function, cardiopulmonary bypass was weaned, cannulas were removed and protamine was administered. Epicardial ventricular pacing wires, a chest tube, and bilateral pleural drains were placed.

Clinical Results

The patient was extubated shortly after arrival in the intensive care unit and experienced an uncomplicated postoperative course. She was discharged home on postoperative day six. At follow-up, imaging demonstrated preserved right ventricular function, unobstructed pulmonary artery flow, and no evidence of valve dysfunction.

Advantages

Pulmonary artery aneurysms (PAA) are rare, and clear indications for surgical intervention remain ill-defined (1). Deb et al. have recommended surgery for symptomatic aneurysms, regardless of size, and for asymptomatic aneurysms measuring over 6 cm in diameter. Patients with right ventricular dysfunction or elevated pulmonary artery pressures should also be considered for operative management (2). The T-shaped graft-valve configuration described here allows for direct anatomic reconstruction of both branch pulmonary arteries while maintaining physiologic flow patterns. Compared with linear conduit reconstruction, this approach minimizes the risk of graft kinking or distortion in the setting of asymmetric branch pulmonary artery dilation. Posterior tilting of the valved conduit further optimizes alignment and flow dynamics.

Caveats

This technique requires extensive mobilization of the branch pulmonary arteries and careful planning of graft geometry. The complexity of multiple anastomoses may increase operative time and necessitates meticulous surgical technique to ensure hemostasis and long-term durability. Broader experience and longer-term follow-up are necessary to determine the reproducibility and durability of this approach.

References

1. Doi A, Gajera J, Niewodowski D, et al. Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension. J Card Surg. 2022;37(4):1019-1025. doi:10.1111/jocs.16235
2. Deb SJ, Zehr KJ, Shields RC. Idiopathic pulmonary artery aneurysm. Ann Thorac Surg. 2005;80(4):1500-1502. doi:10.1016/j.athoracsur.2004.04.011

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.