Tevar With In-situ Laser Fenestration And Carotid Transposition For Management Of Salmonella Pseudoaneurysm Of The Aortic Arch
Saranya Sundaram, MD, Mathew Wooster, MD, MBA RPVI FSVS FACS.
Medical University of South Carolina, Charleston, SC, USA.
Objective: We present a case of hoarseness caused by a thoracic aortic pseudoaneurysm at the level of the left subclavian artery secondary to recent salmonella sepsis. The patient had multiple comorbidities including prior two time sternotomy and left posterolateral thoracotomy for coronary bypass, greater than 90% stenosis of the left internal carotid artery with indication for repair, and inadequate landing zone distal to left subclavian artery complicating his repair options. Methods: The patient was taken to the operating room for concomitant hybrid repair of this symptomatic carotid artery disease and symptomatic arch pseudoaneurysm. Procedure began with transcarotid artery revascularization (TCAR) of the left internal carotid artery via transverse incision at the base of the left neck. This was then followed by left carotid to left subclavian artery transposition. Via percutaneous femoral access utilizing IVUS guidance, a TEVAR was deployed just distal to the innominate artery, occluding the left common carotid and left subclavian artery origins. Finally in situ laser fenestration was performed via the left subclavian artery with placement of a covered, balloon expandable stent. Post operatively the patient has been maintained on chronic suppressive oral antibiotic. Results: The procedure was technically successful with no endoleak and wide patency of the left subclavian and carotid revascularizations. Post-operative course was complicated by lymphatic leak (presumed to be from thoracic duct injury) which resolved with use of octreotide and modified diet. At 1, 6, 12, 18, and 24 month follow up, the patient remains well with CTA demonstrating widely patent revascularization and complete resolution of the pseudoaneurysm. His vocal cord paralysis did not recover but responded well to medialization procedure by an ENT provider. Conclusions: Hybrid procedures can allow treatment of complex aortic pathology not otherwise amenable to surgical intervention. Close surveillance and monitoring for complications is necessary to improve durability of outcomes.
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