Anastomotic leak after aorta surgery usually occurs during the peri-operative period. However late presentation of anastomotic leak can be missed and place surgeons in a challenging situation during re-intervention. Here we report an interesting case of proximal anastomotic leak after ascending aorta replacement which manifested with a huge acute pseudoaneurysm. This patient required emergency repair of the anastomotic leak to tackle the issue.

Anastomotic leak after ascending aorta replacement in aTAAD is rare yet potentially life-threatening complication. It can be divided into two groups: tissue-prosthesis anastomosis leak or prosthesis-prosthesis anastomosis leak [3]. It can also further subgroup into proximal or distal anastomosis leak. Infection undeniably is one of the major causes of anastomotic leak. Other factors could be due to the degeneration of aortic wall, surgical techniques, connective tissue diseases (i.e: Marfan syndrome, Takayasu arteritis) and the false lumen [3,14,16,21].

According to Ghazy et al [3], surgical intervention is granted if the periaortic haematoma compresses on the surrounding structures. Otherwise, patients with asymptomatic anastomotic leak can be managed conservatively with surveillance CTA. Undoubtedly, re-operation is challenging yet an effective definite treatment but with higher morbidity and mortality during peri-operative period¹⁰. In this minimally invasive surgery era, there were studies showed managing anastomotic leak successfully via endovascular approach such as via coiling or transcatheter closure [5-7].

Our patient in this case who presented with vague symptoms making the preliminary diagnosis challenging. Her symptoms were likely due to the mass effect causing by the huge mediastinal haematoma. The mediastinal dense adhesion confined the bleeding and formed huge haematoma, which likely delayed the presentation of anastomotic leak [3]. The elevated WBC suggested an infectious causing the pathology. We opted her for emergency operation in view of her critically ill condition. We studied the CTA and identified the leaking at the proximal anastomotic suturing site. Redo-sternotomy always pose a risk of hazardous re-entry [22-24,26]. Therefore, fem-fem CPB was preferred in this case after considering these factors, such as risks of injury to mediastinal structures, mediastinal adhesion from the recent surgery, and huge haemotoma which compressing the vascular structures^23,26. We explored the left groin to expose the femoral artery and vein.  We initiated fem-fem CPB with two-thirds of flow( 2.53L/min)  to decompress the heart volume. Patient was cooled down to 28’C prior redo-sternotomy. Redo-sternotomy was performed without catastrophic bleeding. Adhesiolysis and removal of the haematoma were performed cautiously. Without excessive mobilisation of the heart, we examined the bleeding point. There was no obvious signs of infection observed except the surrounding tissues appeared friable. We performed direct closure of the bleeding point by using single pledgetted Prolene 6/0 suture with CPB flow manipulation, maintaining it between quarter flow( 3.17L/min) and two third flow( 2.52L/min) intermittently with a close monitoring of cerebral oximetry. Total bypass time was 94 min without circulatory arrest.  We opine that infection could have been the leading cause of anastomotic dehiscence in this case²⁵. Hence, there was no haemostatic sealant or glue used during this operation [27]. Transosoesopheal ECHO (TOE) was performed which showed an optimal repair [12,13]. The aortic valve function was satisfactory. CPB was weaned off with minimal inotropic support. Her chest was closed after achieving good haemostasis. Her immediate postoperative recovery was rather smooth without major adverse event.

Early re-operation for ascending aorta replacement undeniably sets a very high risk of mortality and morbidity. Studies have reported that mortality and morbidity of early re-operation for ascending aorta replacement are as high as 6-19% [8,9,17,19,20]. Nevertheless, the risk and benefit of early intervention should be given adequate consideration. In this patient early intervention was done in view of active contrast leakage, mediastinal haematoma causing pressure symptoms as well as recurrent laryngeal nerve palsy [25]. Surgery has not only allowed a definitive repair, but also relieved the mediastinal compression symptoms by evacuation haematoma which expedited her recovery.