Prosthetic graft cut end aneurysm after total arch replacement: A case report

Prosthetic graft cut end aneurysm after total arch replacement: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Prosthetic graft cut end aneurysm after total arch replacement: A case report Kohei Furusawa, Yuji Kanaoka, Kazuo Tanemoto, Dai Une This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5307360/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Closure of the cut end of prosthetic graft branch can also result in side branch aneurysms, depending on the method of ligation, which can lead to fatal complications Case presentation The patient was an 82-year-old man. He underwent total arch replacement (TAR) 13 years ago at another hospital for Stanford type A chronic aortic dissection. One branch of the four-branched graft for the arterial cannulation was ligated using silk thread after secession of extra-corporeal circulation. He was subsequently followed up at the outpatient department of the nearby hospital. A follow up CT scan revealed enlargement of the four-branched graft ligation site, and suture and closure of the prosthetic graft ligation site was performed under left thoracotomy. The edge of the ligated branch collapsed during dissection and was immediately clamped and closed. The Postoperative course was uneventful, and the patient was discharged from our hospital on postoperative day 13. The patient has been followed up without any complications including recurrence of aneurysm for 4 years since operation. Conclusion Healing mechanisms do not work in anastomosis between prosthetic grafts. The material used such as silk thread may deteriorate over time causing failure. Therefore, it is necessary to use polypropylene or polyester thread for suture and closure. Prosthetic graft Aneurysm Total arch replacement Case report Figures Figure 1 Figure 2 Figure 3 Introduction Although complications, such as anastomotic pseudoaneurysm, can occur following prosthetic graft replacement, the durability of prosthetic grafts is becoming highly satisfactory. 1 , 2 However, there are reports of aneurysms in the non-anastomotic region of prosthetic grafts caused by prosthetic graft failure triggered by kind of infection, although rare. 3 , 4 In this paper, we report, occurrence of closed branch aneurysm of the four-branched graft a13 years after undergoing total arch replacement (TAR) to treat Stanford type A chronic aortic dissection. Case presentation The patient was An 82-year-old male. He underwent TAR using the four-branched graft 13 years before at another hospital for Stanford type A chronic aortic dissection. During the first operation, one branch of the four-branched graft for the arterial cannulation was doubly ligated using silk thread after secession of extra-corporeal circulation. Subsequently, he was being followed up at the outpatient department of a nearby hospital. At 4 years postoperatively, no blood flow was observed at the ligation site of the four-branched prosthetic graft, but a CT scan performed at 10 years and 8 months revealed blood flow at the ligation site. A subsequent CT scan showed enlargement of the blood flow at the ligation site of prosthetic graft. A protruding site was observed on the second branch of the four-branched graft on the lesser curvature side. Based on its location, it was considered to be a branch cut end and ligation site for the arterial cannulation of four-branched after secession of extra-corporeal circulation (Fig. 1 ). Following the size changes in the prosthetic graft cut end aneurysm (prosthetic graft diameter/aneurysm protrusion) over time, the measurements were as follows: 27.9 × 27.4 mm/0 mm (Fig. 2 a) at 3 years 7 months after TAR, 26.1 × 28.0 mm/5.2 mm (Fig. 2 b) at 10 years 8 months after TAR, 27.4 × 29.2 mm/7.35 mm (Fig. 2 c) at 12 years 5 months after TAR, and 27.5 × 29.4 mm/8.0 mm (Fig. 1 ) at 13 years after TAR indicating a gradual enlargement of the prosthetic graft cut end aneurysm. Considering these results, we diagnosed a prosthetic graft cut end aneurysm in the four-branched graft after TAR and scheduled suture and closure of the prosthetic graft branch under a left thoracotomy. For the thoracotomy, we chose a second intercostal approach in a supine position with the patient under general anesthesia. The branched graft was dissected through the left second intercostal space directly below the sternum. As the prosthetic graft branch end started to bleed during dissection, the prosthetic graft branch was immediately clamped. The branch of prosthetic graft was carefully dissected up to the root, the branch was ligated and cut end was closed with a 2 − 0 Ti-Cron™ (nonabsorbable, braided polyester surgical suture: Medtronic Inc, Minneapolis, MN)) using the horizontal mattress + over-and-over technique, and the root part was ligated with a transfixing ligation using a 3 − 0 Prolene™ (uncoated non-absorbable monofilament polypropylene suture : Ethicon Inc. Raritan, NJ, United States). Furthermore, the cut end was closed with a mattress + over-and-over manner using a 4 − 0 Prolene™ suture. A left thoracic tube was inserted for drainage, after which the chest was closed, and the operation was completed. Cut end of the prosthetic graft and the suture was analyzed by pathological examination. The main component was tissue that was suspected to be a prosthetic graft composed of transparent fibrous material (Fig. 3 a, b). The tissue was fused with fibroblasts, fibrous connective tissue, and atypical giant cells. The fibrous material, which was partially colored black, was suspected to be the surgical sutures (Fig. 3 c, d). No abnormalities of particular note were found in such synthetic materials. We also examined the step cut section and found that it mainly consisted of fibrous connective tissue with hardly any fibrous foreign substance that could have been sutures. No sign of infection was found. The patient was admitted to the ICU on the day of operation, and moved to the general ward on postoperative day (POD) 1. There were no major problems, and he was discharged from hospital on POD 13. Five years have passed without any event including recurrence of aneurysm, and the patient is still under observation. Discussion In the present case, the patient underwent TAR to treat Stanford type A chronic aortic dissection, and the method of closing the cut end of prosthetic graft branch was doubly ligated using silk. In a pathological examination of the aneurysm at the cut end of the prosthetic graft, when tissue suspected to be the prosthetic graft was excluded, almost no fibrous foreign body was found suggesting that the ligated silk thread had most likely fallen off or disappeared of tension due to deterioration over time. CT scan, taken three years and seven months after operation revealed no blood flow in the cut end of prosthetic graft branch, and we assumed that deterioration in the suture thread over time or pressure on the prosthetic graft branch moved the ligature to the branch side and formed an aneurysm. Although the cut end broke while we were dissecting the graft, there is also the possibility that a large hemorrhage in the mediastinum could have been fatal even before the operation. A report states that silk thread sutures pose a risk of developing anastomotic pseudoaneurysm. 6 When comparing the different types of surgical sutures, polyester and polypropylene structures are generally thought to be resistant to tissue reaction and maintain their strength in tissue immersion tests and under electron microscopy. In contrast, silk and nylon, containing amide bonds with protein, are destined to be absorbed over time as a result of tissue reaction. In terms of strength deterioration, silk deteriorates the fastest, followed by mesh nylon and monofilament nylon. When prosthetic grafts are connected but fail to heal, the anastomosis may collapse many years after the operation. Therefore, it is desirable to select polyester or polypropylene sutures for the anastomosis of branches in prosthetic grafts. There are no established methods or reports in literature on suturing and closure of the branch cut end. We believe that it is necessary to increase the strength of the anastomosis site using transfixing or repeated ligations with the mattress + over-and-over technique for similar sites such as those found in this case where intravascular pressure becomes high in the aortic arch. At our institution, we are now using 2 − 0 Ti-Cron with the mattress + over-and over technique in addition to our usual double sutures using silk thread for the cut end of prosthetic grafts, and no prosthetic graft cut end aneurysms have been observed. We believe that all the patients who undergo TAR using a prosthetic graft should be monitored throughout their lives. Conclusion We encountered a case where prosthetic graft cut end aneurysm was observed in the non-anastomotic region that was thought to be caused by the closure and ligation method, despite having no failure in 13 years of TAR. Depending on the prosthetic graft closure method, the material used may deteriorate over time causing failure. Therefore, it is necessary to close with suture closure and/or transfixing ligation using polypropylene or polyester thread not only with silk thread ligation. Furthermore, in cases of prosthetic graft replacement where there is branch closure or graft-to-graft anastomosis, regular monitoring by imaging is necessary, as the situation can be fatal. Abbreviations TAR Total arch replacement CT Computed tomography POD Postoperative day Declarations Ethics approval and consent to participate This study was approved by Kawasaki Medical School Hospital Ethics Committee. IRB number: 6183-01 (12 October 2023). Informed consent was obtained from the patient. Consent for publication The patient consented to the publication of this report. Competing interests The authors declare no competing interests. Funding None. Acknowledgements None. Authors' information Authors and Affiliations Department of Cardiovascular surgery, Kawasaki Medical School Hospital , 577, Matsushima, Kurashiki-shi, Okayama-ken 701-0192, Japan Kohei Furusawa, Yuji Kanaoka, Kazuo Tanemoto and Dai Une Contributions YK and KT were in charge of this case and KF were responsible for writing this report. DU contributed to the treatment decisions. All authors contributed to the refinement of the case report and approved the final manuscript. Corresponding author Correspondence to Kohei Furusawa. References Nagano N, Cartier R, Zigras T, et al. Mechanical properties and microscopic findings of a Dacron graft explanted 27 years after coarctation repair. J Thorac Cardiovasc Surg. 2007;134(6):1577–8. Cooley DA, Subran A, Houchin DP. Clinical experience in 1,040 patients with double-velour knitted Dacron vascular prosthesis with paticular reference to dilation and aneurysm formation. Cardiovasc Dis. 1981;8(3):320–31. Wilson SE, Krug R, Mueller G, et al. Late disruption of Dacron aortic grafts. Ann Vasc Surg. 1997;11(4):383–6. Berger K, Sauvage LR. Late fibre deterioration in Dacron arterial grafts. Ann Surg. 1981;193(4):477–91. Attaran S, Field M, Kuduvalli M, et al. True aneurysm of a Dacron tube graft 19 years after repair of coarctation of the aorta. Ann Thorac Surg. 2010;90(3):1000–1. Moore WS, Hall AD. Late suture failure in the pathogenesis of anastomotic psudoaneurysms. Cardiovasc. Ann Surg. 1970;172(6):1064–8. Roy J, Guidoin R, Cardou A, et al. Cardiovascular sutures as assessed by scanning electron microscopy. Scan Electron Microsa. 1980;3:203–10. Tsang JS, Naughton PA, Wang TT, et al. Endovascular repair of para-anastomotic aortic aneurysm. Cardiovasc Intervent Radiol. 2009;32(6):1165–70. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5307360","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":369862747,"identity":"0e551fa7-bcb4-41d5-aac5-5cf8623c5cc7","order_by":0,"name":"Kohei Furusawa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYBAC9gZknkQFkGBmbsCqFAZ4DiDzLM6AtDCSoqWyDUQS0iKR+0zyR81heQbp5gMMN+fVRvO3A7X8qNiGR0u6mTTPscOGDTLHEhhnbjueO+MwYwNjz5nbOLXYS6SxSTOw3WZskMgxYJbcdiy3AaiFmbENtxYeoBbJH/9u24O1/J1zLHc+MVokeNtuJ4K0MEg21ORuIKiF5xmzNW/f/+Q2ibSEAxLHDuRuBGo5iM8vPOxpjDd/fEuz7ZdIPvhAoqYud975wwcf/KjArQUO2ID4AAPDYTDnAGH1CFBHiuJRMApGwSgYIQAAm/BU9Ob+9vMAAAAASUVORK5CYII=","orcid":"","institution":"Kawasaki Medical School Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kohei","middleName":"","lastName":"Furusawa","suffix":""},{"id":369862748,"identity":"2350d433-32e5-4f8b-bc81-7e79f1ec7f67","order_by":1,"name":"Yuji Kanaoka","email":"","orcid":"","institution":"Kawasaki Medical School Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Kanaoka","suffix":""},{"id":369862749,"identity":"a91aba15-d815-4f3d-87e7-1da633dce5c5","order_by":2,"name":"Kazuo Tanemoto","email":"","orcid":"","institution":"Kawasaki Medical School Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kazuo","middleName":"","lastName":"Tanemoto","suffix":""},{"id":369862750,"identity":"204d786b-6428-49d6-b7ef-579d677674aa","order_by":3,"name":"Dai Une","email":"","orcid":"","institution":"Kawasaki Medical School Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dai","middleName":"","lastName":"Une","suffix":""}],"badges":[],"createdAt":"2024-10-22 00:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5307360/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5307360/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67620386,"identity":"7b617e7e-102f-4956-9586-2abf2e51dcb1","added_by":"auto","created_at":"2024-10-28 07:00:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":480461,"visible":true,"origin":"","legend":"\u003cp\u003eContrasted-enhanced CT (First consultation at our hospital)\u003c/p\u003e\n\u003cp\u003ea: Plain CT\u003c/p\u003e\n\u003cp\u003eb: Contrasted-enhanced CT(arterial phase)\u003c/p\u003e\n\u003cp\u003ec: Contrasted-enhanced CT(venous phase)\u003c/p\u003e\n\u003cp\u003ed: Contrasted-enhanced CT (3 dimensional construction)\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5307360/v1/72fec9d9f4d15185eae2238c.png"},{"id":67620385,"identity":"7239e954-d1e1-4a18-b28b-fbb5eafb1d9a","added_by":"auto","created_at":"2024-10-28 07:00:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":527047,"visible":true,"origin":"","legend":"\u003cp\u003eContrasted-enhanced CT /3 dimensional construction\u003c/p\u003e\n\u003cp\u003ea: 3 years and 7 months after TAR\u003c/p\u003e\n\u003cp\u003eb: 10 years and 8 months after TAR\u003c/p\u003e\n\u003cp\u003ec: 12 years and 5 months after TAR\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5307360/v1/f49e53d968b9d8edd3c7754c.png"},{"id":67620384,"identity":"655aec42-b7b2-4397-93d2-f322fa2fcb0a","added_by":"auto","created_at":"2024-10-28 07:00:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1262412,"visible":true,"origin":"","legend":"\u003cp\u003ePathological examination\u003c/p\u003e\n\u003cp\u003ea: The prosthetic graft (10x)\u003c/p\u003e\n\u003cp\u003eb: The prosthetic graft (40x)\u003c/p\u003e\n\u003cp\u003eThe fiber of prosthetic graft.\u003c/p\u003e\n\u003cp\u003ec: The suture (10x)\u003c/p\u003e\n\u003cp\u003ed: The suture (40x)\u003c/p\u003e\n\u003cp\u003eThe partially colored black was suspected to be the surgical sutures (←).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5307360/v1/3c63c470bc19dc76ac939ee9.png"},{"id":85628974,"identity":"96836ec8-36c6-4613-a111-727e245d0d0c","added_by":"auto","created_at":"2025-06-30 02:23:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2556500,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5307360/v1/e98dfb81-60c8-46b2-89e9-d094d0121a30.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prosthetic graft cut end aneurysm after total arch replacement: A case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough complications, such as anastomotic pseudoaneurysm, can occur following prosthetic graft replacement, the durability of prosthetic grafts is becoming highly satisfactory.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, there are reports of aneurysms in the non-anastomotic region of prosthetic grafts caused by prosthetic graft failure triggered by kind of infection, although rare.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this paper, we report, occurrence of closed branch aneurysm of the four-branched graft a13 years after undergoing total arch replacement (TAR) to treat Stanford type A chronic aortic dissection.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was An 82-year-old male. He underwent TAR using the four-branched graft 13 years before at another hospital for Stanford type A chronic aortic dissection. During the first operation, one branch of the four-branched graft for the arterial cannulation was doubly ligated using silk thread after secession of extra-corporeal circulation. Subsequently, he was being followed up at the outpatient department of a nearby hospital. At 4 years postoperatively, no blood flow was observed at the ligation site of the four-branched prosthetic graft, but a CT scan performed at 10 years and 8 months revealed blood flow at the ligation site. A subsequent CT scan showed enlargement of the blood flow at the ligation site of prosthetic graft.\u003c/p\u003e\u003cp\u003eA protruding site was observed on the second branch of the four-branched graft on the lesser curvature side. Based on its location, it was considered to be a branch cut end and ligation site for the arterial cannulation of four-branched after secession of extra-corporeal circulation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFollowing the size changes in the prosthetic graft cut end aneurysm (prosthetic graft diameter/aneurysm protrusion) over time, the measurements were as follows: 27.9 × 27.4 mm/0 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea) at 3 years 7 months after TAR, 26.1 × 28.0 mm/5.2 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb) at 10 years 8 months after TAR, 27.4 × 29.2 mm/7.35 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec) at 12 years 5 months after TAR, and 27.5 × 29.4 mm/8.0 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) at 13 years after TAR indicating a gradual enlargement of the prosthetic graft cut end aneurysm.\u003c/p\u003e\u003cp\u003eConsidering these results, we diagnosed a prosthetic graft cut end aneurysm in the four-branched graft after TAR and scheduled suture and closure of the prosthetic graft branch under a left thoracotomy.\u003c/p\u003e\u003cp\u003eFor the thoracotomy, we chose a second intercostal approach in a supine position with the patient under general anesthesia. The branched graft was dissected through the left second intercostal space directly below the sternum. As the prosthetic graft branch end started to bleed during dissection, the prosthetic graft branch was immediately clamped. The branch of prosthetic graft was carefully dissected up to the root, the branch was ligated and cut end was closed with a 2 − 0 Ti-Cron™ (nonabsorbable, braided polyester surgical suture: Medtronic Inc, Minneapolis, MN)) using the horizontal mattress + over-and-over technique, and the root part was ligated with a transfixing ligation using a 3 − 0 Prolene™ (uncoated non-absorbable monofilament polypropylene suture : Ethicon Inc. Raritan, NJ, United States). Furthermore, the cut end was closed with a mattress + over-and-over manner using a 4 − 0 Prolene™ suture. A left thoracic tube was inserted for drainage, after which the chest was closed, and the operation was completed.\u003c/p\u003e\u003cp\u003eCut end of the prosthetic graft and the suture was analyzed by pathological examination.\u003c/p\u003e\u003cp\u003eThe main component was tissue that was suspected to be a prosthetic graft composed of transparent fibrous material (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, b).\u003c/p\u003e\u003cp\u003eThe tissue was fused with fibroblasts, fibrous connective tissue, and atypical giant cells. The fibrous material, which was partially colored black, was suspected to be the surgical sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec, d). No abnormalities of particular note were found in such synthetic materials.\u003c/p\u003e\u003cp\u003eWe also examined the step cut section and found that it mainly consisted of fibrous connective tissue with hardly any fibrous foreign substance that could have been sutures. No sign of infection was found.\u003c/p\u003e\u003cp\u003eThe patient was admitted to the ICU on the day of operation, and moved to the general ward on postoperative day (POD) 1. There were no major problems, and he was discharged from hospital on POD 13. Five years have passed without any event including recurrence of aneurysm, and the patient is still under observation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present case, the patient underwent TAR to treat Stanford type A chronic aortic dissection, and the method of closing the cut end of prosthetic graft branch was doubly ligated using silk. In a pathological examination of the aneurysm at the cut end of the prosthetic graft, when tissue suspected to be the prosthetic graft was excluded, almost no fibrous foreign body was found suggesting that the ligated silk thread had most likely fallen off or disappeared of tension due to deterioration over time. CT scan, taken three years and seven months after operation revealed no blood flow in the cut end of prosthetic graft branch, and we assumed that deterioration in the suture thread over time or pressure on the prosthetic graft branch moved the ligature to the branch side and formed an aneurysm. Although the cut end broke while we were dissecting the graft, there is also the possibility that a large hemorrhage in the mediastinum could have been fatal even before the operation. A report states that silk thread sutures pose a risk of developing anastomotic pseudoaneurysm.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e When comparing the different types of surgical sutures, polyester and polypropylene structures are generally thought to be resistant to tissue reaction and maintain their strength in tissue immersion tests and under electron microscopy. In contrast, silk and nylon, containing amide bonds with protein, are destined to be absorbed over time as a result of tissue reaction. In terms of strength deterioration, silk deteriorates the fastest, followed by mesh nylon and monofilament nylon. When prosthetic grafts are connected but fail to heal, the anastomosis may collapse many years after the operation. Therefore, it is desirable to select polyester or polypropylene sutures for the anastomosis of branches in prosthetic grafts. There are no established methods or reports in literature on suturing and closure of the branch cut end. We believe that it is necessary to increase the strength of the anastomosis site using transfixing or repeated ligations with the mattress\u0026thinsp;+\u0026thinsp;over-and-over technique for similar sites such as those found in this case where intravascular pressure becomes high in the aortic arch. At our institution, we are now using 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Ti-Cron with the mattress\u0026thinsp;+\u0026thinsp;over-and over technique in addition to our usual double sutures using silk thread for the cut end of prosthetic grafts, and no prosthetic graft cut end aneurysms have been observed. We believe that all the patients who undergo TAR using a prosthetic graft should be monitored throughout their lives.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe encountered a case where prosthetic graft cut end aneurysm was observed in the non-anastomotic region that was thought to be caused by the closure and ligation method, despite having no failure in 13 years of TAR.\u003c/p\u003e \u003cp\u003eDepending on the prosthetic graft closure method, the material used may deteriorate over time causing failure. Therefore, it is necessary to close with suture closure and/or transfixing ligation using polypropylene or polyester thread not only with silk thread ligation. Furthermore, in cases of prosthetic graft replacement where there is branch closure or graft-to-graft anastomosis, regular monitoring by imaging is necessary, as the situation can be fatal.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal arch replacement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative day\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by Kawasaki Medical School Hospital Ethics Committee. IRB number: 6183-01 (12 October 2023). Informed consent was obtained from the patient.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe patient consented to the publication of this report.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eAuthors' information\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliations\u003c/p\u003e\n\u003cp\u003eDepartment of Cardiovascular surgery, Kawasaki Medical School Hospital , 577, Matsushima, Kurashiki-shi, Okayama-ken 701-0192, Japan\u003c/p\u003e\n\u003cp\u003eKohei Furusawa, Yuji Kanaoka, Kazuo Tanemoto and Dai Une\u003c/p\u003e\n\u003cp\u003eContributions\u003c/p\u003e\n\u003cp\u003eYK and KT were in charge of this case and KF were responsible for writing this report. DU contributed to the treatment decisions. All authors contributed to the refinement of the case report and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eCorrespondence to Kohei Furusawa.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNagano N, Cartier R, Zigras T, et al. Mechanical properties and microscopic findings of a Dacron graft explanted 27 years after coarctation repair. J Thorac Cardiovasc Surg. 2007;134(6):1577\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooley DA, Subran A, Houchin DP. Clinical experience in 1,040 patients with double-velour knitted Dacron vascular prosthesis with paticular reference to dilation and aneurysm formation. Cardiovasc Dis. 1981;8(3):320\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson SE, Krug R, Mueller G, et al. Late disruption of Dacron aortic grafts. Ann Vasc Surg. 1997;11(4):383\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger K, Sauvage LR. Late fibre deterioration in Dacron arterial grafts. Ann Surg. 1981;193(4):477\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAttaran S, Field M, Kuduvalli M, et al. True aneurysm of a Dacron tube graft 19 years after repair of coarctation of the aorta. Ann Thorac Surg. 2010;90(3):1000\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore WS, Hall AD. Late suture failure in the pathogenesis of anastomotic psudoaneurysms. Cardiovasc. Ann Surg. 1970;172(6):1064\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoy J, Guidoin R, Cardou A, et al. Cardiovascular sutures as assessed by scanning electron microscopy. Scan Electron Microsa. 1980;3:203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsang JS, Naughton PA, Wang TT, et al. Endovascular repair of para-anastomotic aortic aneurysm. Cardiovasc Intervent Radiol. 2009;32(6):1165\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prosthetic graft, Aneurysm, Total arch replacement, Case report","lastPublishedDoi":"10.21203/rs.3.rs-5307360/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5307360/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eClosure of the cut end of prosthetic graft branch can also result in side branch aneurysms, depending on the method of ligation, which can lead to fatal complications\u003c/p\u003e\n\u003cp\u003eCase presentation\u003c/p\u003e\n\u003cp\u003eThe patient was an 82-year-old man. He underwent total arch replacement (TAR) 13 years ago at another hospital for Stanford type A chronic aortic dissection. One branch of the four-branched graft for the arterial cannulation was ligated using silk thread after secession of extra-corporeal circulation. He was subsequently followed up at the outpatient department of the nearby hospital. A follow up CT scan revealed enlargement of the four-branched graft ligation site, and suture and closure of the prosthetic graft ligation site was performed under left thoracotomy. The edge of the ligated branch collapsed during dissection and was immediately clamped and closed. The Postoperative course was uneventful, and the patient was discharged from our hospital on postoperative day 13. The patient has been followed up without any complications including recurrence of aneurysm for 4 years since operation.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eHealing mechanisms do not work in anastomosis between prosthetic grafts. The material used such as silk thread may deteriorate over time causing failure. Therefore, it is necessary to use polypropylene or polyester thread for suture and closure.\u003c/p\u003e","manuscriptTitle":"Prosthetic graft cut end aneurysm after total arch replacement: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-28 07:00:44","doi":"10.21203/rs.3.rs-5307360/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6285d73e-ab58-4da6-a3f8-adf78c629567","owner":[],"postedDate":"October 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T02:23:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-28 07:00:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5307360","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5307360","identity":"rs-5307360","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}