Peripheral Matters | Introduction: Pseudoaneurysm of the aorta is a rare and high-risk complication following cardiac and thoracic surgery and is due to weakness of either layer (intima, media, or adventitia) of the aortic wall, resulting in damage of the layer of the wall and covered by remaining vessel layers and/or surrounding structures. Pseudoaneurysms typically have a narrow neck and a high risk of rupture. There are several sites for development of pseudoaneurysms after surgery involving the ascending aorta, including the clamping site, graft anastamosis, needle site, and cannulation site.^1,2

Traditionally, open surgical repair is the treatment of choice but has been associated with very poor outcomes; mortality can reach up to 21% in specific patients.³ This article describes a novel approach with transvascular repair of a pseudoaneurysm of the ascending aorta post cardiac surgery using an Amplatzer atrial septal defect (ASD) occluder device (St. Jude Medical, U.S.) with intracardiac echocardiogram and fluoroscopic guidance.

Case Report

A 66-year-old Caucasian female with a previous medical history of severe mitral regurgitation and severe tricuspid regurgitation who recently underwent double valve repair and MAZE procedure at another hospital is transferred post-operatively. She was actually discharged from the hospital after her double valve replacement and then presented to the emergency department at her local hospital two weeks post-procedure with complaints of right shoulder pain and continuous bloody drainage anteriorly through her sternal wound incision. After undergoing computed tomography angiography (CTA) of the chest, she is found to have a 3.2 cm pseudoaneurysm of the thoracic aorta near the site of aortic cannulation and is transferred to another facility for a higher level of care (FIGURE 1). At the request of the cardiac surgery department, the patient is seen and assessed by the interventional cardiology service, and the transthoracic echocardiogram and CT images are evaluated, deeming her a candidate for possible percutaneous closure after a multidisciplinary meeting with our heart valve team.

Procedure Description

The patient is brought to the catheterization lab and prepped and draped in sterile fashion after informed consent is obtained. Arterial and venous access is obtained using the modified Seldinger technique with a micropuncture needle. The right common femoral artery is pre-closed with a 6F Perclose ProGlide (Abbott Vascular, U.S.) and upsized to an 11 Fr Pinnacle 10 cm sheath (Terumo Medical Corp, U.S.). A 6 Fr Pinnacle 10 cm sheath is placed in the left common femoral artery, and an 11 Fr Pinnacle 10 cm sheath is placed in the right common femoral vein.

Using a 5 Fr labeled Performa Pigtail VSC 20B (Merit Medical System, Inc, USA) and exchange length (0.035 x 300 cm) Storq Soft Guidewire (Johnson and Johnson, USA) are advanced through the left common femoral artery. The pigtail is placed in the aortic root, and angiography is performed, delineating the pseudoaneurysm in multiple views (FIGURE 2).

Unfractionated heparin (100 U/kg) is administered intra-arterially, and the results of an activated clotting time (ACT) test are adequate prior to advancement of the 10 Fr Intracardiac echocardiography (ICE) catheter (Biosense Webster, USA) through the venous sheath into the superior vena cava. Intracardiac echocardiography imaging demonstrates a pseudoaneurysm of the ascending aorta with bidirectional shunting through a 6 mm defect in the anterior aspect of the aortic wall (FIGURE 3).

Using a 6 Fr LCB Vista Brite Tip 100 cm guide catheter (Johnson & Johnson) and the previous Storq Soft Guidewire, the pseudoaneurysm is successfully cannulated. Angiography is again performed, further delineating the pseudoaneurysm; subsequently, a 0.025 x 230 cm Toray spiral Guidewire (Toray International America, Inc, U.S.) is exchanged for the Storq Soft Guidewire and positioned in the pseudoaneurysm for support. The 6 Fr LCB catheter is then removed (FIGURE 4).

An Amplatzer Torque 45 Degree Delivery System (St. Jude Medical) is advanced co-axially over a 7 Fr LCB Vista Brite Tip 100 cm guide catheter over the Toray spiral guidewire. The pseudoaneurysm is cannulated with the LCB guide catheter and the Amplatzer Torque Delivery sheath was then advanced through the defect and into the pseudoaneurysm cavity over the LCB guide. The LCB guide provided support as well as a gradual transition to the relatively large inner diameter of the Amplatz delivery sheath. The LCB guide and the Toray spiral guide wire are then removed. A 6 mm ASD occluder is then delivered and successfully placed across the pseudoaneurysm, obliterating all flow through the defect into the pseudoaneurysm. Correct positioning is confirmed with angiography and intracardiac echocardiography (FIGUREs 5 and 6). The delivery system is then removed, and the pre-close sutures are tied and secured with complete hemostasis. Aortic root angiography confirms no residual shunting across the pseudoaneurysm (FIGURE 7). The 5 Fr pigtail and intracardiac echocardiography catheter are then removed.

The day following the procedure, her sternal bleeding stops, and her chest pain is resolved. She is discharged in good condition 7 days post-intervention. The patient returns for follow-up 2 weeks post-procedure. Her sternal wound is completely healed, her chest and shoulder pain have resolved, and she has been asymptomatic since the time of discharge.

Discussion

Although relatively rare, pseudoaneurysms of the aorta are a known and recognizable complication of cardiac surgery, thoracic surgery, and trauma to the chest wall.1,2 Currently, surgical repair is the most common treatment for pseudoaneurysms; however, this procedure is associated with very high morbidity and mortality, and is sometimes not possible.^3,4 Several percutaneous techniques have been described in the past, such as stent graft and coil implantation.⁵ Additionally, injection of thrombin into the pseudoaneurysm has also been described treatment.⁶ There have also been a few reports demonstrating that successful closure of the pseudoaneurysm may be obtained with a percutaneous approach using an occluder device.^7-10 Stasek et al. demonstrated that closure is possible, and associated with acceptable long-term patient prognosis at follow-up 2 years post-procedure.⁷ This case report demonstrates successful use of an Amplatzer occluder device in the treatment of a large pseudoaneurysm of the ascending aorta. It is important to fully evaluate the anatomical definition of the pseudoaneurysm with the various available cardiac imaging modalities prior to deciding which intervention is preferable (surgical vs. percutaneous). Some important factors that will determine if a percutaneous approach is possible include sufficient rim of the defect, sufficient distance from vital structures, no signs of peripheral infections, size of sac, and presence of thrombus.

Conclusion

This case demonstrates that percutanous repair of a pseudoaneurysm of the ascending aorta post cardiac surgery using an Amplatzer atrial septal (ASD) occluder device can be performed successfully with excellent immediate and long-term outcomes, and denotes the importance of having a multidisciplinary heart valve team to help develop the best innovate care plan for the patient. Since experience is limited, more studies are required to comment on mortality benefits for these patients.

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References

1. Sullivan KL, Steiner RM, Smullens SN, et al. Chest. 1988;93:138-43.
2. Razzouk A, Gundry S, Wang N, et al. Ann Surg. 1993;59:818-23.
3. Allen RC, Schneider J, Longenecker L, et al. J Vasc Surg. 1993;18:424-31.
4. D’Attellies N, Diemont FF, Julia PL, et al. Ann Thorc Surgery. 2001;71:1010-1.
5. Fann JI, Samuels S, Slonim S, et al. J Vasc Surg. 2002;35:811-4.
6. Lin PH, Bush RL, Tong FC, et al. J Vasc Surg. 2001;34:939-42.
7. Stasek J, Polansky P, Bis J, et al. Can J Cardiol. 2008;24:e99-e101.
8. Kanani RS, Neilan TG, Palacios IF, et al. Cath Cardiovasc Interv. 2007;69:146-53.
9. Bashir F, Quaife R, Carroll JD. Catheter Cardiovascular. Interventions. 2005;65:547-51
10. Agarwal M, Ray M, Pallavi M, et al. Ann Pediatr Cardiol. 2011;4:195-9.

Keywords: CardioSource WorldNews Interventions, Adventitia, Aneurysm, False, Angiography, Aorta, Aorta, Thoracic, Cardiac Surgical Procedures, Catheterization, Chest Pain, Echocardiography, Femoral Artery, Femoral Vein, Heart Septal Defects, Atrial, Heart Valves, Hemostasis, Heparin, Mitral Valve Insufficiency, Thoracic Surgery, Thoracic Wall, Thorax, Tomography, Tricuspid Valve Insufficiency, Tunica Media

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