Abstract: Massive Aortic Pseudoaneursym and Hemoptysis Following Delayed Migration of Methylmethacrylate for Chest Wall Reconstruction (Plastic Surgery 2015)

Saturday, October 17, 2015

Kathryn L Parker, MD , General Surgery, University of California San Diego, San Diego, CA

Patricia Thistlethwaite, MD , Cardiothoracic Surgery, University of California San Diego, San Diego, CA

Eugene M Golts, MD , Cardiothoracic Surgery, University of California San Diego, San Diego, CA

Mayer Tenenhaus, MD, FACS , Plastic Surgery, University of California San Diego, San Diego, CA

Fernando Herrera, MD , Division of Plastic Surgery, Medical University of South Carolina, Ralph Johnson VA Medical Center, Charleston, SC

Christopher M Reid, MD , Plastic Surgery, University of California, San Diego, San Diego, CA

Zaynoun El Khoury, MD , Cardiothoracic Surgery, University of California San Diego, San Diego, CA

Ahmed S Suliman, MD , Plastic Surgery, University of California, San Diego, San Diego, CA

Presentation PDF file

E-Poster

Background:

Chest wall defects greater than 5 centimeters generally require skeletal reconstruction to prevent flail physiology.^1-2 Autologous bone and fascia lata have been replaced with rigid prosthetics such as the methylmethacrylate mesh "sandwich." This permanent, rigid framework can be contoured to any defect and avoids donor site morbidity. It is also more malleable than metal hardware and radiolucent, thus easily seen on imaging. We report the first case of both delayed methylmethacrylate migration and resultant pseudoaneurysm and discuss post-operative management considerations.

Methods:

A 58-year-old woman with a 15-centimeter left posterior chest wall mass was taken to the operating room. After posteriolateral thoracotomy was performed, a latissimus dorsi flap was created by freeing the muscle's medial and lateral attachments. The underlying mass was then resected en bloc with ribs 5-9 and scapula tip. A sandwich of outer Prolene mesh and inner methylmethacrylate was contoured to the chest wall. 3-0 Prolene running sutures affixed the bilayer mesh to the thoracic wall. The flap and overlying tissues were then closed in a standard layered fashion.

Results:

Pathology revealed a benign spindle cell tumor. The patient had an uncomplicated recovery until fourteen months post-operatively, when she developed new chest pain following back massage. CT scan revealed minor plate migration, which was stable on four serial follow-up images. However, two years later, the patient presented to the emergency room with sudden hemoptysis. CT scan revealed further plate migration (Figure 1), a 5.3 x 8.7 x 17.8-centimeter descending aortic pseudoaneurysm (Figure 2), and aortic branch fistulization with pulmonary vasculature. An endovascular aortic stent was placed emergently and the patient's hemoptysis resolved. She is planned for elective prosthetic removal and reconstruction.

Conclusions:

Published complications with methylmethacrylate reconstruction relate primarily to slight increased infection rate compared with autologous grafts or mesh alone.³ Only one series reported plate migration in two patients, which occurred immediately post-operatively.⁴ This first reported case of delayed migration highlights the need for long-term follow-up. As overlying muscle flap and soft tissue coverage may render physical exam unreliable, CT imaging to document anatomical plate placement is warranted. If migration is noted, early operative repair may prevent eventual erosion into vital intra-thoracic structures.

Legends:

1. Methylmethacrylate plate abutting descending aorta to right and posterior pseudoaneursym

2. Massive left-sided pseudoaneurysm

27936 Massive Aortic Pseudoaneursym and Hemoptysis Following Delayed Migration of Methylmethacrylate for Chest Wall Reconstruction