Gallbladder Infarction Complication after Total Arch Replacement

(Department of Cardiovascular Surgery, and Department of Pathology*, Mitsubishi Kyoto Hospital, Kyoto, Japan)

Atsushi Shimizu Hiroyuki Nakajima Hiroaki Osada
Atsushi Nagasawa Masahisa Kyogoku
A 73-year-old man was referred to our hospital for treatment of a sacral aneurysm of the distal aortic arch with a maximum dimension of 66mm. He underwent total arch replacement(TAR)with cardiopulmonary bypass(CPB), moderate hypothermia, circulatory arrest(CA)of the lower body and antegrade selective cerebral perfusion(SCP)via a median sternotomy. Through the aneurysm, the descending aorta was divided and distal anastomosis was performed using the stepwise technique. After the inserted tube graft was extracted, a four-branched arch graft was anastomosed. The arch vessels and the proximal aorta were then anastomosed to the four-branched graft. The operation time was 515min, CPB time was 305min, aorta cross clamp(ACC)time was 213min, SCP time was 143min, and CA of the lower body was 97min. On postoperative day(POD)5, right-upper abdominal pain suddenly developed, with low grade fever. Acute cholecystitis was suspected and antibiotic therapy was started. On POD 6, his abdominal pain shifted to the lower-right region. His blood examination results were unchanged. Acute peritonitis was suggested by abdominal-enhanced computed tomography(CT), and emergency open cholecystectomy was then performed. There was no evidence of gall stones, and a bacterial culture of the ascites was negative. The pathological diagnosis was thromboendarteritis of the gallbladder artery, accompanied with thrombophlebitis and thrombosis, causing massive infarction at the neck of the gallbladder wall. His postoperative course was uneventful and he discharged in an ambulatory state on POD 16. In TAR, the risk of gastrointestinal ischemia is considerable because of prolonged circulatory arrest of the lower body and debris embolism. It is necessary to recognize possible gallbladder infarction, although it is rare, as a differential diagnosis of acute abdomen after TAR.
  Jpn. J. Cardiovasc. Surg. 40:77-80(2011)

Keywords:gallbladder infarction, total arch replacement, circulatory arrest