Multidisciplinary Approach To Percutaneous Closure Of Iatrogenic Ascending Aortic Pseudoaneurysms Following Open Aortic Repair
Fanny S. Alie-Cusson, MD1, Thekla Bacharach, MBBS1, Julia Stehli, MD2, Paul D. Mahoney, MD FACC2, Jean M. Panneton, MD FRCSC FACS1.
1Eastern Virginia Medical School, Norfolk, VA, USA, 2Sentara Heart Valve and Structural Disease Center, Norfolk, VA, USA.
OBJECTIVES: Iatrogenic ascending aortic pseudoaneurysms (IAAP) are a rare, but life-threatening complication following cardiac surgery. Most occur at the graft anastomoses and require repair, regardless of size or location, due to risk of catastrophic rupture. Timing and modality of repair remain controversial. Open surgical repair can be challenging and is associated with substantial morbidity and mortality. TEVAR is mainly limited by the absence of a proximal landing zone and potential coverage of coronary arteries. Direct percutaneous transcatheter closure offers an attractive minimally invasive option.
METHODS: We present a case series of four consecutive percutaneous IAAP repairs performed at our institution between December 2018 and June 2020.
RESULTS: Case 1 is a 74-year-old male who underwent ascending aortic graft (AAG) replacement for an ascending aortic aneurysm (AscAA). Follow-up CTA at 2 months revealed a 9.4 cm IAAP along the proximal anastomosis of the AAG. Given the 10 mm neck size, this was repaired using an 11 mm Amplatzer septal occluder (ASO, Abbott, IL, USA) with immediate thrombosis of the pseudoaneurysm sac. Case 2 is a 56-year-old male who presented with chest pain and voice hoarseness following total arch replacement with CABG using a saphenous vein graft (SVG) for an aortic arch aneurysm. CTA revealed multiple IAAPs anterior and posterior to the AAG. He underwent re-do sternotomy which was aborted due to extensive adhesions. The distal IAAP was treated with TEVAR. A 3.1 cm persistent proximal IAAP at the origin of the SVG was treated with coil embolization. Case 3 is a 56-year-old woman with prior repair of an acute type A aortic dissection with an AAG. Follow-up CTA at 5 months revealed an 11.8 cm anterior mediastinal IAAP at the proximal anastomosis, rendering redo-sternotomy prohibitive. Case 4 is 57-year-old male who had undergone repair of an AscAA with an AAG four years prior. Follow-up CTA revealed a 3.8 cm IAAP at the distal anastomosis. Both IAAPs were treated using an 11 mm ASO. There were no procedural complications. Follow-up CTA revealed complete IAAP thrombosis in all 4 patients at a mean follow-up of 6 months.
CONCLUSIONS: This case series illustrates how a multidisciplinary approach to a lethal complication using minimally invasive endovascular therapies can lead to successful outcomes.
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