Percutaneous Closure of a Large Ascending Aortic Pseudoaneurysm

www.revportcardiol.org

Revista

Portuguesa

de

Cardiologia

Portuguese

Journal

of

Cardiology

CASE

REPORT

Percutaneous

closure

of

a

large

ascending

aortic

pseudoaneurysm

Marta

Afonso

Nogueira

_,

_António

_Fiarresga

_,

_Lídia

_de

_Sousa

_,

Ana

Galrinho

_,

_Ninel

_Santos

_,

_Isabel

_Nobre

_,

_Álvaro

_Laranjeira

_,

Rui

Cruz

Ferreira

a_{DepartmentofCardiology,SantaMartaHospital,Lisbon,Portugal} b_{DepartmentofRadiology,LusíadasHospital,Lisbon,Portugal}

c_{DepartmentofCardiothoracicSurgery,SantaMartaHospital,Lisbon,Portugal}

Received27April2015;accepted16October2015

Availableonline3February2016

KEYWORDS Ascendingaorta; Pseudoaneurysm; Percutaneousclosure

Abstract Pseudoaneurysmoftheascendingaortaisararecomplication,usuallyafterthoracic

surgeryortrauma.

Since surgical repair is associated with very high morbidity and mortality, percutaneous

closurehasbeendescribedasanalternative.

In this regard,we present acase in which a symptomatic large pseudoaneurysm of the

ascendingaortawastreatedpercutaneouslyduetothehighsurgicalrisk.

Despitethetechnicaldifficulties,thisprocedurehadagoodfinalresultfollowedbyclinical

success.

©2016SociedadePortuguesa deCardiologia.Publishedby ElsevierEspaña,S.L.U.All rights

reserved. PALAVRAS-CHAVE Aortaascendente; Pseudoaneurisma; Encerramento percutâneo

Encerramentopercutâneodeumvolumosopseudoaneurismadaaortaascendente Resumo Opseudoaneurismadaaortaascendenteconsistenumacomplicac¸ãorara,

habitual-mentenasequênciadecirurgiacardiotorácicaoutraumatismo.

Dado queareparac¸ãocirúrgicadomesmose associaaumaelevada morbimortalidade,o

encerramentopercutâneotemvindoaserdescritocomoumaalternativaviável.

∗_{Correspondingauthor.}

E-mailaddress:marta.afonso.nogueira@gmail.com(M.A.Nogueira). http://dx.doi.org/10.1016/j.repc.2015.09.021

Neste contexto,apresentamosum casocaracterizadoporum volumosoe sintomático

pseu-doaneurismadaaortaascendente,oqualforasubmetidoatratamentopercutâneo,devidoao

elevadoriscocirúrgico.

Apesardasdificuldadesdopontodevistatécnico,esteprocedimentoobteveumbom

resul-tadofinal,comsucessoemtermosclínicos.

©2016SociedadePortuguesadeCardiologia.PublicadoporElsevierEspaña,S.L.U.Todosos

direitosreservados.

Introduction

Pseudoaneurysmoftheascendingaortaisarelativelyrare but serious complication that usually develops following thoracicsurgery,includingaorticvalvereplacement, coro-nary artery bypass grafting, aortic dissection repair and orthotopiccardiactransplantation.1---5_{Theincidenceofthis}

complication following aortic surgery can reach 23% at 15 years after surgery. Other potential etiologies include endocarditisandthoracictrauma.6

Figure1 Imaging ofascendingaortic pseudoaneurysm.(A)Transthoracic echocardiographyshowingascending aortic

pseudo-aneurysminparasternalview;(B)three-dimensionalcomputedtomography(CT)reconstructionofaorta;(C)CTscanwith

intra-venouscontrastshowingthedimensionsoftheneckandcavityofthepseudoaneurysm;(D)aortographywithcontrastopacification

ofpseudoaneurysmcavity(solidarrows).

Clinical presentation ranges from completely asymp-tomaticfor yearstosymptomsrelated tothemasseffect onsurroundingstructures.6

Ifleftuntreated,aorticpseudoaneurysmscanevolveto rupture,thrombosis,distalembolizationandfistula forma-tion,withhighmortality(upto61%).6

Surgical repairof thiscomplication isthe conventional treatment, but it is associated with very high morbidity andmortality(mortalitycanreach46%)andinsomecases is not even feasible (due to the technical difficulties in

Figure2 Images illustratingpercutaneousclosureofaortic pseudoaneurysm. (A)Left internalmammary diagnosticcatheter

insidethedeliverysheathengagingthepseudoaneurysmcavity;(B)Amplatzeratrialseptaldefect(ASD)occluderwiththedistal

diskopenedinsidethepseudoaneurysmcavity,andtheproximaldiskmisshapeninsidetheaorticlumen;(C)AmplatzerASDdevice

deployedacrosstheaorticwalldefect;(D)AmplatzerASDdevicereleasedinastableposition;(E)transthoracicechocardiography

showingpositionofthedevicewithoutinterferingwiththebioprosthesis.

patients who have undergone prior complex thoracic sur-geries),sopercutaneousclosure hasbeendescribed asan alternative.1---6

Inthepast,severalpercutaneoustechniquesforclosure of a pseudoaneurysm have been attempted such asstent grafting, coil implantation or thrombin injection, but the finalresultsobtainedweresuboptimal.Inrecentyears, dif-ferent types of deviceshave occasionallybeen usedwith successinoff-labelindications.Thefirstpercutaneous clo-surewaspublishedin2005,butexperiencesincethenhas beenlimited,usuallytopatientsnotsuitableforsurgeryor withhighsurgicalrisk.Thelatestcasewaspublishedin2014, withagoodfinalresultandwithoutcomplications.2---4,6

Over-all,thesuccessratefor percutaneousclosureis80%,with a 12% device embolization rate and an 8% failure rate of thetranscathetertechniquetoclosethepseudoaneurysm, necessitatingconversiontosurgicalclosure.5,6

Wepresentacaseinwhichasymptomaticlarge pseudo-aneurysmoftheascendingaortawastreatedpercutaneously duetothepatient’shighsurgicalrisk.

Case

report

An 81-year-old man with a history of aortic bioprosthe-sisimplanted duetosevere aorticregurgitation,coronary

arterydisease(treatedbypercutaneoustransluminal coro-nary angioplasty of the mid left anterior descending artery),arterial hypertensionand dyslipidemia,was eval-uated for atypical thoracic pain, after an asymptomatic period of two years post surgery. The patient was med-icated with aspirin 100 mg daily, lisinopril 20 mg daily, carvedilol 6.25 mg twice daily, omeprazole 20 mg daily androsuvastatin10mg,withgoodcontrolof vascularrisk factors.

During complementary investigation, a chest X-ray showed widening of the mediastinal silhouette and a transthoracicechocardiogram revealed a pseudoaneurysm of the ascending aorta, 35 mm above the aortic valve (Figure1A).

Coronary computed tomography angiography (CCTA) (Figure1Band 1C)andaortography(Figure1D)confirmed alarge pseudoaneurysm(98 mm×48mm) anda defectin theaorticwall(19mm×19mm).

The patientwas considered to beat high surgical risk (EuroSCORE II of 12.21%) and was referred for percuta-neous treatment (closure of the pseudoaneurysm with a non-dedicateddevice).

Firstofall,anattemptwasmadewitha9FAmplatzer®

TorqueVue® _{deliverysheaththrougharight femoralartery}

Figure3 Evolutionovertimeofascendingaortic pseudoaneurysmclosure.(A andB)Computedtomography(CT) scanatone

monthshowingAmplatzerASDdeviceinastablepositionandorganizingthrombusinsidethepseudoaneurysmcavity;(CandD)CT

scanatoneyearwithdevicemaintainingitspositionandpartialresolutionoftheexcludedpseudoaneurysmcavity.

standard 0.035 wire and a left internal mammary diag-nostic catheter inside the delivery sheath, but this was too short and did not enter the pseudoaneurysm cavity (Figure 2A). The sheath was then changed to a 12 F St. Jude®_/Daig®_{sheaththatsuccessfullyenteredthe}

pseudoa-neurysm. A 20 mm Amplatzer® _{atrial septal defect (ASD)}

occluder was used, although considerable resistance was encountered navigating the device and it was impossible to proceed behind the aortic arch. An 8F Judkins Right guidecatheter,withitsproximaltipcut,wasplacedinside the delivery sheath for extra support, in a mother-child technique,enabling the deviceto navigatedistally inthe sheath. At first, the proximaldisk did not conformto its originalconfiguration(Figure2B),butafteraseriesof care-ful retrieval and reposition maneuvers the device finally acquiredastableposition(Figure2C---E).

CCTA at one month (Figure 3A and B) and 12 months (Figure3C andD) after theprocedure showed thedevice correctlypositionedandcompleteclosureofthe pseudoa-neurysmwiththrombosisofitscavity.

After14monthsoffollow-upthepatientremains asymp-tomaticandwithoutanyevents.

Discussion

and

conclusion

This case report illustrates a relatively rare complication of thoracic surgery, namely an ascending aorta pseudoa-neurysm.

Althoughsurgicalrepairremainsthedefinitivetherapy,in viewofthepatient’shighperioperativeriskhewastreated bypercutaneousclosureofthepseudoaneurysm,whichhas ahigh(80%)successrate,asdescribedintheliterature.2---6

Experiencewithpercutaneousclosureofaortic pseudo-aneurysms has increased steadily since the introduction of the technique in 2005, with several benefits, includ-ingfewerpotentialcomplicationsandavoidanceofsurgical risk.6

Inthiscase,despiteallthetechnicaldifficulties,the pro-cedurehadbothimagingandclinicalsuccess,renderingthe patientasymptomaticandwithouteventsinafollow-upof overoneyear.

Consequently,thisresultconfirmsthatpercutaneous clo-sure witha non-dedicateddevice isan effective andsafe alternative to surgery asa definitive treatment in aortic pseudoaneurysms.

Ethical

disclosures

Protection of human and animal subjects.The authors declarethatnoexperimentswereperformedonhumansor animalsforthisstudy.

Confidentialityofdata.Theauthorsdeclarethattheyhave followedtheprotocolsoftheirworkcenteronthe publica-tionofpatientdata.

Righttoprivacyandinformedconsent.Theauthorshave obtained the written informedconsent of thepatients or subjectsmentionedinthearticle.Thecorrespondingauthor isinpossessionofthisdocument.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

References

1.D’Attellies N, Diemont FF, Julia PL, et al. Management of pseudoaneurysm of the ascending aorta performed under

circulatory arrest by port-access. Ann Thorc Surg. 2001;71: 1010---1.

2.BashirF,QuaifeR,CarrollJD.Percutaneousclosureofascending aorticpseudoaneurysmusingAmplatzerseptaloccluderdevice: thefirstclinicalcasereportandliteraturereview.Catheter Car-diovascInterv.2005;65:547---51.

3.Kanani RS, Neilan TG, Palacios IF, et al. Novel use of the Amplatzer septaloccluder deviceinthe percutaneousclosure of ascendingaortic pseudoaneurysms: acase series.Catheter CardiovascInterv.2007;69:146---53.

4.StasekJ,PolanskyP,BisJ,etal.Thepercutaneousclosureofa largepseudoaneurysmoftheascendingaortawithanatrialseptal defectAmplatzeroccluder:two-yearfollow-up.CanJCardiol. 2008;24:e99---101.

5.NobleS,IbrahimR.EmbolizationofanAmplatzermVSDoccluder device usedfor percutaneous closure of an ascending aortic pseudoaneurysm: casereport and literaturereview. Catheter CardiovascInterv.2012;79:334---8.

6.Patel AV,Gupta S, Laffin LJ, et al. One size does notfit all: case report of two percutaneous closures of aortic pseudo-aneurysmandreviewoftheliterature.CardiovascRevascMed. 2014;15:160---4.