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Image-guided Percutaneous Coil Embolization of Ascending Aortic Pseudo-aneurysm
Ahmed Mohamed, MD, Ponraj Chinnadurai, MBBS, MMST, Kavya Sinha, MD, Mahesh Ramchandani, MD, Alan Lumsden, MD.
Houston Methodist Hospital, Houston, TX, USA.

Objective:
To demonstrate a novel approach to percutaneous coil embolization of ascending aortic pseudo aneurysm using an intra-operative image fusion guidance system.
Methods:
A 77 year old female s/p valve-sparing aortic root and ascending aorta replacement (David-V procedure) for ascending aortic aneurysm presented 1 month later with syncopal episode. CTA showed a distal suture line pseudo-aneurysm. The initial attempt for trans-arterial access and embolization of pseudo-aneurysm was unsuccessful due to small neck.
Repeat CTA 2 days later showed enlargement of the pseudo-aneurysm and mediastinal hematoma. The patient was taken to the operating room for possible endovascular or open repair of the pseudo aneurysm.
With the goal of re-attempting percutaneous embolization, intraoperative cone beam CT imaging (syngo DynaCT®, Siemens Healthcare GmbH, Germany) was performed using a 4-second scan protocol and fused with preoperative CTA images. On the 3D post-processing workstation, a virtual needle trajectory was planned using commercially available software (syngo Needle Guidance®, Siemens). After image fusion the planned needle trajectory was pushed to the fluoroscopic imaging system and the skin access point was delineated with the integrated laser cross-hairs. Using a needle stabilization system (SeeStar®, AprioMed AB, Sweden), an 18G needle was advanced 4.5 cms into the pseudoaneurysm. Successful access was confirmed by direct angiography via the needle. Successful coil embolization was then performed via the aforementioned needle.
Results:
Completion angiogram and contrast-enhanced cone-beam CT imaging showed no evidence of flow inside the pseudo aneurysm. Follow-up CTA on the third postoperative day showed that the coils were positioned inside the pseudo aneurysm with complete thrombosis of its cavity. The patient was discharged home in a stable condition.
Conclusion:
Image-fusion guided percutaneous coil embolization of aortic pseudo-aneurysm provides a minimally invasive treatment option and may help avoid major surgical approaches such as redo sternotomy.


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