Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y R ev i ew

Chu et al.
MDCT of Aortic Root Surgical Complications

Vascular and Interventional Radiology

Review
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FOCUS ON:

MDCT Evaluation of Aortic Root

Surgical Complications
Linda C. Chu1 OBJECTIVE. CT is the primary imaging modality used after aortic root repair. Distinc-
Pamela T. Johnson1 tion of normal findings from postoperative complications is imperative and requires optimi-
Duke E. Cameron2 zation of acquisition parameters and interpretation with advanced postprocessing tools.
Elliot K. Fishman1 CONCLUSION. After aortic root surgery, findings can be categorized as complications
within the aorta, complications outside the aorta, and benign postoperative changes. Distinc-
Chu LC, Johnson PT, Cameron DE, Fishman EK tion of normal findings from postoperative complications requires proper CT technique and
an understanding of CT findings that require intervention.

Keywords: aneurysm, aorta graft, CT angiography,
dissection, pseudoaneurysm
DOI:10.2214/AJR.12.10010
Received September 26, 2012; accepted after revision
October 29, 2012.
1
The Russell H. Morgan Department of Radiology and
Radiological Science, Johns Hopkins Hospital, JHOC
3254, 601 N Caroline St, Baltimore, MD 21287. Address
correspondence to E. K. Fishman (efishman@jhmi.edu).
2
Department of Surgery, Division of Cardiac Surgery,
Johns Hopkins Hospital, Baltimore, MD.
CME/SAM
This article is available for CME/SAM credit.
AJR 2013; 201:736744
0361803X/13/2014736
American Roentgen Ray Society
S
ince Bentall and De Bono [1] in-
troduced the surgical technique of
composite mechanical aortic valve
conduit replacement in 1968, sur-
gical modifications and technical improve-
ments during the past 3 decades have made
aortic root repair safe and reproducible. Al-
though the expected mortality rate in elective
aortic root repair is less than 5% [2, 3], pa-
tients who undergo aortic root repair are at
risk of developing early- and late-term post-
operative complications. With increased num-
bers of patients undergoing aortic root repair
and advances in imaging techniques, these
postoperative complications may be detected
at a higher frequency. Accurate diagnosis of
these complications is critical in presurgical
planning. The purpose of this article is to de-
scribe CT protocol optimization when imag-
ing these patients and to review the CT find-
ings across a spectrum of aortic root surgical
complications. The review is organized into
complications within the aorta, complica-
tions outside the aorta, and benign postopera-
tive changes that may simulate postoperative
complications (Table 1).
CT Technique
At our institution, prospective or retrospec-
tive ECG gating is performed for patients with
a history of aortic root surgery to minimize
motion artifact at the aortic root. Our scans
are performed on a 64-MDCT scanner (So-
matom 64, Siemens Healthcare) or a dual-
source 128-MDCT scanner (Somatom Flash,
Siemens Healthcare). The scan parameters
are optimized for each patient but are in the
range of 120 kVp, 180250 effective mAs, de-
tector collimation of 0.6 mm, and slice thick-
ness of 0.75 mm. Patients receive 100120 mL
(2 mL/kg) of iohexol 350 (Omnipaque, GE
Healthcare) or iodixanol 320 (Visipaque, GE
Healthcare) injected IV at a rate of 46 mL/s
via a power injector. The scan is triggered
via a bolus-tracking or test-bolus technique.
An unenhanced CT scan is not performed
for routine surveillance of asymptomatic pa-
tients with histories of aortic root surgeries.
There are specific indications where the ad-
ditional radiation from unenhanced imaging
is justified. These include patients who have
stent grafts, to distinguish calcification from
endoleak, and patients with acute chest pain
in whom intramural hematoma is a potential
cause. In select cases where graft material
mimics a leak and an unenhanced acquisition
was not performed, comparison with prior ex-
aminations or delayed imaging can be per-
formed to make the distinction.
Optimal image interpretation requires inter-
active 2D multiplanar reconstruction and 3D
volume rendering to display aortic root patho-
logic abnormalities [4]. This is best performed
by the interpreting radiologist, to avoid mis-
interpretation of findings limited to static im-
ages. Because of the configuration of the aor-
tic root and ascending thoracic aorta, display
is optimized by use of coronal and sagittal
planes, as illustrated by the cases presented
here. This is helpful to both distinguish normal
surgical appearance from leak, dissection, or
pseudoaneurysm and to show complications

736 AJR:201, October 2013

 MDCT of Aortic Root Surgical Complications
TABLE 1: Spectrum of Aortic Root Surgical Complications and Benign Postoperative Changes That May Simulate
Postoperative Complications
Complication Within the Aortic Root
Pseudoaneurysm
True aneurysm
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Dissection
Endoleak
Coronary ostial aneurysm
to the surgeon. Interactive examination also
allows tailoring of advanced postprocessing
tools (e.g., multiplanar reconstructions, maxi-
mum intensity projection, volume rendering,
and semiautomated vessel tracking) to the indi-
vidual case depending on the anatomic configu-
ration and the pathologic abnormality present.
Complications Within the Aorta
Potential complications within the aorta in-
clude pseudoaneurysm, true aneurysm, dissec-
tion, endoleak, and coronary ostial aneurysm.
Aortic Root Pseudoaneurysms
Aortic root pseudoaneurysm is a rare com-
plication and develops in less than 0.5% of
cases after cardiac surgery [5]. Mediastinitis
and graft infection are the most common risk
factor for the formation of postoperative aor-
tic root pseudoaneurysms [57]. Other risk
factors include progressive aortic wall dis-
ease (i.e., Marfan syndrome and Takayasu ar-
teritis), dissection of the native aorta, and ex-
cessive use of biologic glue [7, 8]. The most
common location for postoperative pseudo
aneurysm is the graft anastomosis site (Figs.
1 and 2), followed by coronary artery anas-
tomosis site (Fig. 3), aortotomy site, aortic
cannulation site, and needle vent site [69].
Although many patients present with acute
symptoms, such as chest pain, heart failure,
and sepsis [7, 8, 10, 11], some patients can
be relatively asymptomatic (Fig. 4). Regard-
less, a pseudoaneurysm carries high risk of
rupture; delayed phase images are helpful in
identifying active extravasation (Fig. 5).
There have been only a few case reports of
successful endovascular treatment of postop-
erative aortic root pseudoaneurysms [1214]
(Fig. 5), and aortic graft replacement remains
the treatment of choice. Pseudoaneurysms
situated anterior to the aorta and less than 2
cm from the sternum are considered at high
risk for surgical reentry (Fig. 4), and car-
diopulmonary bypass should be established
before resternotomy [7, 11]. In some cases,
aortic root pseudoaneurysm may recur after
AJR:201, October 2013 737
Complication Outside the Aortic Root
Pulmonary embolism Elephant trunk procedure
Hemothorax Aortic arch debranching with arterial reimplantation
Mediastinitis Hyperdense surgical material
Sternal dehiscence
Perigraft seroma
operative repair [11, 15] (Fig. 5). Therefore,
surveillance CT is recommended to evaluate
for recurrence of pseudoaneurysms [7].
True Aneurysm and Dissection
Patients with a history of aortic root repair
may develop progressive aortic root aneurysm
or dissection that requires reoperation [16]
(Fig. 6). Those with underlying connective tis-
sue disorder, such as Marfan syndrome, are
especially at increased risk for requiring reop-
eration after aortic root repair [3]. Therefore,
these patients must undergo imaging follow-
up to monitor the aortic root graft.
Endoleak
Patients with aneurysms extending from
the aortic root to the descending thoracic aor-
ta may undergo a combination of open sur-
gical aortic root repair and endovascular re-
pair of aortic arch aneurysm [17, 18]. Like all
patients who undergo endovascular repairs,
these patients are at risk of developing en-
doleaks [18, 19] (Fig. 7). Proximal landing
zone angulation is likely to be a significant
risk factor for endoleak and stent-graft col-
lapse. Type 1 endoleak occurring after stent-
graft implantation can be treated by perform-
ing balloon angioplasty of the prosthesis [19].
On surveillance CT scans, unenhanced im-
ages are particularly useful in distinguishing
stent-graft material from endoleak.
Coronary Ostial Aneurysm
Coronary ostial aneurysm can develop at
the coronary artery reimplantation site, es-
pecially in patients with underlying connec-
tive tissue disorder such as Marfan syndrome
and Loeys-Dietz syndrome [2022] (Fig. 8).
Coronary ostial aneurysms develop in up to
43% of patients with Marfan syndrome, and
it is thought to develop as a result of peri-
operative stretch of the weakened coronary
ostial wall [21]. Some authors advocate sur-
gical repair of these coronary ostial aneu-
rysms [20, 22, 23], whereas others suggest
that these coronary ostial aneurysms repre-
Benign Postoperative Changes
sent low-risk findings [21]. Long-term conse-
quences of these coronary ostial aneurysms
remain unknown [24].
Complications Outside the Aorta
Potential complications outside the aorta
include pulmonary embolism, mediastinitis,
sternal dehiscence, and perigraft seroma.
Pulmonary Embolism
Patients with a recent history of major sur-
gery, such as aortic root repair, are at increased
risk of developing pulmonary embolism, par-
ticularly those who do not receive anticoag-
ulation therapy after valve replacement. Pa-
tients with pulmonary embolism may present
with nonspecific symptoms, such as chest pain
and dyspnea, and the clinical presentation may
be confused with other aortic root complica-
tions (i.e., pseudoaneurysm or dissection). It is
important to consider the possibility of pulmo-
nary embolism (Fig. 9), because management
of pulmonary embolism (i.e., anticoagulation
therapy or inferior vena cava filter placement)
is clearly different from that of surgical aortic
root complications. If pulmonary embolism is
considered in the clinical differential diagno-
sis, scan acquisition timing must be modified
to adequately enhance both pulmonary arteries
and the thoracic aorta.
Hemothorax
Patients who undergo aortic root repair are
also at risk of developing postoperative he-
mothorax, which can require thoracotomy
and surgical drainage. On CT, hemothorax
appears as a hyperattenuating fluid collection
within the chest (Fig. 10). CT with IV con-
trast agent may be helpful in identifying the
source of bleeding and to exclude aortic root
complications, such as pseudoaneurysm, as
the cause.
Mediastinitis
The incidence of mediastinitis after car-
diac surgery is reported to be 0.45%, with
a mortality rate of 2750% [25]. In the early

postoperative period, it is difficult to differ-
entiate mediastinitis from benign postopera-
tive fluid and air in the surgical site on the
basis of imaging appearance alone. A small
amount of fluid or gas may be seen for sever-
al days or weeks after removal of mediastinal
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drains [26]. On CT, the presence of abnor-
mally large amounts of low-attenuation ma-
terial surrounding the aortic graft or increas-
ing fluid and soft-tissue infiltration on serial
scans and the presence of gas raise suspicion
for mediastinitis [27] (Fig. 11). The clinical
presentation of fever, chest pain, and sepsis
is also key to the diagnosis of mediastinitis.
Sternal Dehiscence
Sternal dehiscence and sternal wound in-
fections are serious complications, with a re-
ported incidence of less than 17% in patients
who have undergone cardiac surgery. Risk
factors include obesity, lung disease, diabe-
tes, history of chest wall radiation, renal dis-
ease, steroid use, and reoperation [28]. Sternal
dehiscence may occur alone or in association
with mediastinitis [29]. CT findings in ster-
nal dehiscence include displacement of ster-
nal wires [29], sternal erosion [30], or cleft
within the sternotomy site (Fig. 12).
Perigraft Seroma
Perigraft seroma is a rare late complication
of polytetrafluoroethylene and polyester fiber
(Dacron, DuPont) grafts [31, 32] (Fig. 13). The
pathogenesis of perigraft seromas involves
both failure of graft incorporation into the na-
tive vessel wall and increased graft porosity
[33]. Fluid between the open aortic graft and
the sac wall is a normal finding on imaging in
the period immediately after surgery. Howev-
er, after 3 months, any perigraft hematoma or
fluid should have resolved [33]. Perigraft se-
romas may recur after simple aspiration and
drainage of seroma fluid [31] (Fig. 13).
Benign Postoperative Changes
Benign postoperative changes that may
mimic complications include complex surgi-
cal repair, such as elephant trunk procedure,
aortic arch debranching with arterial reim-
plantation, and hyperdense surgical material.
Elephant Trunk Procedure
The elephant trunk graft is used for patients
with diffuse thoracic aortic disease requiring
a two-stage repair. The ascending thoracic
aorta is repaired in the first stage with a free-
floating graft (the elephant trunk), which ex-
tends from the aortic arch into the descending
738 AJR:201, October 2013
Chu et al.
thoracic aorta. The descending thoracic aorta
is then repaired in the second stage by either
open repair or endovascular stent-graft repair,
using the free-floating graft as the proximal
fixation zone [34, 35]. Contrast agent within
the native descending thoracic aorta at the lev-
el of the free-floating graft can mimic an en-
doleak (Fig. 14). Multiplanar reconstruction
and understanding of the normal postopera-
tive appearance of the elephant trunk proce-
dure can help avoid misinterpreting the CT ap-
pearance of the enhancing lumen surrounding
the graft as a leak or the free-floating graft as
a dissection flap.
Aortic Arch Debranching With Arterial
Reimplantation
Aortic arch aneurysms can also be repaired
via sequential debranching and reimplanta-
tion of supraoartic vessels and endovascular
stent-graft placement [17]. The reimplanted
vessels can mimic pseudoaneurysms on axial
CT images (Fig. 15). Multiplanar reconstruc-
tion and 3D volume rendering are critical for
depicting the entire course of the reimplant-
ed vessels and in distinguishing them from
pseudoaneurysms.
Hyperdense Surgical Material
Surgical material, such as felt strips and
felt pledgets, have high attenuation on CT
and may mimic contrast material (Fig. 16).
Felt strips are often used to buttress the aor-
tic anastomosis in patients with a fragile aor-
tic wall. Felt pledgets may be seen at sites of
intraoperative needle or cannula placement
within the graft or native aorta [27]. Unen-
hanced CT images serve to distinguish hy-
perdense surgical material from contrast
extravasation (Fig. 16). Multiplanar recon-
struction and 3D volume rendering may also
help distinguish coronary buttons at the cor-
onary artery reimplantation sites from con-
trast extravasation (Fig. 17).
Conclusion
Although aortic root surgical complica-
tions are rare, those that involve the aorta
and those beyond the aorta can be life threat-
ening. MDCT with ECG gating, well-timed
contrast enhancement, and advanced post-
processing tools for interpretation can pro-
vide important diagnostic information in ac-
curate diagnosis and presurgical planning.
The radiologist must be involved from pro-
tocol planning to interactive interpretation, to
accurately differentiate true surgical compli-
cations from their mimickers.
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Fig. 126-year-old man with Marfan syndrome, who
underwent aortic root replacement and mitral valve
replacement, who presented with chest pain.
A and B, Axial (A) and sagittal (B) ECG-
gated contrast-enhanced CT images show
pseudoaneurysm (arrow) arising from graft
anastomosis site posterior to aortic root.
Fig. 265-year-old man who underwent aortic valve
replacement, who presented with mediastinitis and
sepsis.
A, Axial unenhanced CT image shows hyperdense
fluid collection (arrows) adjacent to aortic root.
B, Axial ECG-gated contrast-enhanced CT image
shows multiple pseudoaneurysms (arrowheads)
arising from aortic valve anastomosis.
 Chu et al.

Fig. 343-year-old woman with Marfan syndrome

who underwent aorta root repair.
A, ECG-gated sagittal oblique CT image shows
pseudoaneurysm (arrow) along anterior aspect of
ascending aorta.
B, ECG-gated coronal oblique color-coded volume-
rendered CT image better depicts pseudoaneurysm
(white arrow) as it arises from right coronal artery
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anastomosis site (black arrow). Case was previously

described by Johnson et al. [4] and Chu et al. [9].

A B

Fig. 472-year-old man with aortic valve

replacement, coronary artery bypass graft surgery,
and mitral valve replacement who was receiving
long-term warfarin therapy and who was admitted
for management of sigmoid colon mass. Aortic root
pseudoaneurysm was incidentally found on staging CT.
A and B, Axial (A) and sagittal (B) nonECG-
gated contrast-enhanced CT images show large
pseudoaneurysm (arrow) anterior to aortic root,
immediately posterior to sternum. Proximity to
sternum carries high risk of reentry hemorrhage and
necessitates cardiopulmonary bypass before surgery.

A B

Fig. 559-year-old man with Marfan syndrome

who underwent multiple aortic root surgeries and
pseudoaneurysm repair.
A, Axial ECG-gated contrast-enhanced CT image
obtained during arterial phase shows small
pseudoaneurysm (black arrow) anterior to aortic root
and mediastinal hematoma (white arrow), resulting in
superior vena cava syndrome.
B, Delayed phase image shows active contrast agent
extravasation (arrowheads). Patient underwent
urgent operative repair.
(Fig. 5 continues on next page)
A B

740 AJR:201, October 2013

 MDCT of Aortic Root Surgical Complications

Fig. 5 (continued)59-year-old man with Marfan

syndrome who underwent multiple aortic root
surgeries and pseudoaneurysm repair.
C, Seven-month follow-up axial ECG-gated contrast-
enhanced CT image shows new pseudoaneurysm
(arrow) arising near left coronary artery anastomosis
site.
D, Axial ECG-gated contrast-enhanced CT image
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shows successful embolization of aortic root

pseudoaneurysm (arrow).

C D

Fig. 657-year-old man with aortic valve

replacement who presented with chest pain and
dyspnea.
A and B, Axial ECG-gated contrast-enhanced CT
image (A) and sagittal ECG-gated volume-rendered
CT image (B) show ascending aortic aneurysm
(arrow) with new focal dissection flap.

A B

Fig. 766-year-old woman with history of coronary

artery bypass graft, ascending aortic aneurysm
repair, and endovascular repair of descending
thoracic aortic aneurysm, who presented for routine
follow-up examination.
A and B, Axial (A) and sagittal (B) ECG-gated
contrast-enhanced CT images show type 3 endoleak
(arrow).
A B

AJR:201, October 2013 741

 Chu et al.
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A B
Fig. 823-year-old man with Marfan syndrome and ascending aortic dissection requiring valve-sparing aortic
root replacement.
A, Axial ECG-gated contrast-enhanced CT image shows aneurysmal dilatation of right coronary artery
reimplantation site (arrow).
B, Sagittal ECG-gated color-coded volume-rendered CT image better shows right and left coronary artery
ostial aneurysms (arrows) at implantation sites.

Fig. 946-year-old man with history of sinus of
Valsalva fistula repair 3 years ago who presented
with chest pain. Axial non-ECG-gated contrast-
enhanced CT image shows right lower lobe
pulmonary embolus (arrow).
Fig. 1046-year-old man with Marfan syndrome
who underwent thoracic aortic aneurysm repair,
with clinical concern for postoperative hemorrhage.
Axial unenhanced CT image shows large hemothorax
(arrow), which required surgical evacuation.

Fig. 1126-year-old woman with Marfan syndrome

who underwent aortic root and aortic arch
replacement.
A, Axial ECG-gated contrast-enhanced CT image
obtained 1 week after operation shows small amount
of air and fluid (arrow) surrounding aortic root graft,
compatible with expected postoperative change.
B, Patient presented with chest pain, dyspnea, and
sepsis, and follow-up axial ECG-gated contrast-
enhanced CT image obtained 5 days later shows
interval increase in size of fluid collection (arrow)
surrounding aortic graft, which was suspicious for
mediastinitis. Bacterial culture of fluid collection was
positive for Serratia marcescens.
A B

742 AJR:201, October 2013

 MDCT of Aortic Root Surgical Complications
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Fig. 1259-year-old man with aortic root
replacement, left ventricular myomectomy, and
patent foramen ovale closure, who presented
with chest pain and chest swelling. Axial ECG-
gated contrast-enhanced CT image shows sternal
dehiscence with large bilateral pectoral hematomas.
Fig. 1342-year-old woman with history of aortic
root composite graft repair who presented with
recurrent seroma surrounding aortic root graft.
Coronal ECG-gated contrast-enhanced CT image
shows thin-walled low-attenuation fluid collection
(arrow) surrounding aortic root graft.

A B
Fig. 1482-year-old woman who underwent ascending aortic arch elephant trunk procedure.
A and B, Axial (A) and sagittal (B) ECG-gated contrast-enhanced CT images show distal end of elephant trunk graft
(arrow) suspended within descending thoracic aorta, which can be mistaken for endoleak or dissection flap.

A B
Fig. 1571-year-old woman with history of distal arch and descending thoracic aortic aneurysm and type B
aortic dissection who underwent debranching of aortic arch with reimplantation of innominate artery and left
common carotid artery.
A, Axial ECG-gated contrast-enhanced CT image shows outpouching of contrast agent (arrow) along right
anterior aspect of aortic root, which simulates aortic root pseudoaneurysm.
B, Sagittal ECG-gated color-coded volume-rendered CT image shows that outpouching of contrast agent
(arrow) along right anterior aspect of aortic root seen on axial image represents reimplantation site of
innominate artery and left common carotid artery.

AJR:201, October 2013 743

 Chu et al.

Fig. 1617-year-old boy with Marfan syndrome and

type A aortic aneurysm who underwent aortic root
and aortic valve replacement.
A, Axial ECG-gated contrast-enhanced CT image
shows hyperdense material (arrow) anterior to aortic
root, which can simulate pseudoaneurysm.
B, Axial unenhanced CT image shows that
hyperdense material (arrow) represents surgical
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material and not contrast agent extravasation.

A B

Fig. 1786-year-old woman with history of coronary

bypass graft.
A, Axial ECG-gated contrast-enhanced CT image
shows hyperdense material (arrow) anterior to aortic
root, which can simulate pseudoaneurysm.
B, Coronal ECG-gated color-coded volume-rendered
CT image shows that hyperdense material (arrows)
represents coronary buttons at reimplantation sites
and not pseudoaneurysms.

A B

F O R YO U R I N F O R M AT I O N
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744 AJR:201, October 2013