Ann Thorac Surg 2009;87:1281-1284. doi:10.1016/j.athoracsur.2008.07.053
© 2009 The Society of Thoracic Surgeons
Case Reports
Successful Exclusion of Large Post-Surgical Pseudoaneurysms of the Ascending Aorta by a Percutaneous Approach
Bhava R.J. Kannan, MDa,
Ajay K. Jain, MRCPb,
Shakeel A. Qureshi, MD, FRCPa,*,
Martin T. Rothman, FRCP, FESCb,
Eric Rosenthal, MD, FRCPa,
Anthony Mathur, PhD, MRCPb
a Department of Congenital Heart Disease, Evelina Children's Hospital, London, United Kingdom
b Department of Cardiology, London Chest Hospital, London, United Kingdom
Accepted for publication July 11, 2008.
* Address correspondence to Dr Qureshi, Department of Congenital Heart Disease, Evelina Children's Hospital, Westminster Bridge Rd, London, SE1 7EH, United Kingdom (Email: shakeel.qureshi{at}gstt.nhs.uk).
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Abstract
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Two patients, aged 60 and 63 years, presented with a pseudoaneurysm of the ascending aorta arising from the cannulation site or suture line after previous cardiac surgery. Successful exclusion of the aneurysm was performed in both patients percutaneously using Amplatzer muscular ventricular septal defect occluders.
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Introduction
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Pseudoaneurysm of the ascending aorta is a rare but known complication after cardiac surgery [1–4]. The most serious consequence of these is rupture, so treatment is needed [1]. However, surgery may be complicated by adhesions and possible exsanguination during sternotomy [4]. We report our experience with 2 patients in whom post-surgical pseudoaneurysms were treated with the Amplatzer muscular ventricular septal defect occluder. Both patients were referred by the surgeons and vascular radiologists for interventional treatment, as the surgeons considered them to be of unacceptably high risk and the vascular radiologists considered them unsuitable for stent-graft exclusion because of the size of the ascending aorta or proximity to the innominate artery in 1 patient. The procedure was performed in a catheter laboratory with surgical standby.
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Case Reports
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Patient 1
A 60-year-old hypertensive man presented 2 years previously with acute dissection of ascending aorta extending into the descending aorta. This was treated surgically by the insertion of a Dacron interposition tube graft (W. L. Gore & Associates, Flagstaff, AZ) into the ascending aorta and re-suspension of the aortic valve. One year later he presented with left-sided chest pain with progressive dyspnea. A contrast-enhanced computed tomographic scan revealed a large pseudoaneurysm measuring 55 mm in diameter arising from the ascending aorta (Figs 1A and 1C). The opening from the aorta measured 9 mm in diameter. Surgery was believed to carry an unacceptably high risk, so a percutaneous approach was recommended.
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Fig 1. (A) Contrast-enhanced computed tomographic scan showing faint opacification of large pseudoaneurysm with a narrow communication to the ascending aorta (arrows). (B) No contrast seen entering the pseudoaneurysm. Arrows indicate position of the Amplatzer muscular ventricular septal defect occluder. (C) Anteroposterior projection showing the delivery sheath positioned within the pseudoaneurysm. Black arrows and the guidewire show the extent of the aneurysm. (D) Post-device deployment aortogram showing no filling of the pseudoaneurysm. Arrows indicate position of the Amplatzer muscular ventricular septal defect occluder.
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Under general anesthesia, using the right femoral artery, a catheter was passed into the ascending aorta. An ascending aortogram delineated the pseudoaneurysm, which was away from the ostia of the coronary arteries. Due to the tortuosity of the iliac arteries and the descending aorta, a standard 80-cm long 10-French Amplatz torque view sheath failed to reach the pseudoaneurysm, so a left brachial arteriotomy was used. The pseudoaneurysm was entered with a super floppy guidewire, followed by an 80-cm Amplatzer torque view sheath passed over a 0.035" wire. A 10-mm Amplatzer muscular ventricular septal defect occluder was delivered at the aortic opening of the pseudoaneurysm. An ascending aortogram showed stable device position with exclusion of the pseudoaneurysm, further confirmed by a computed tomographic scan 72 hours later (Figs 1B, 1D). The patient was discharged on 75 mg of aspirin once daily. He was asymptomatic 6 months later.
Patient 2
A 63-year-old lady presented with a slowly enlarging pulsatile mass on the upper right parasternal region. Sixty years previously, she underwent descending aorta-to-left pulmonary artery anastomosis (Pott's shunt) for tetralogy of Fallot. This was revised to a classical right Blalock-Taussig shunt 11 years later. Complete repair was performed 12 years later with a transannular patch. Five years later, she needed further surgery after developing an aneurysm of the right ventricular outflow. Recently she noticed a small swelling at the upper sternum, which increased in size and was visibly pulsatile. A computed tomographic scan of the chest revealed a pseudoaneurysm from the ascending aorta measuring 45 mm from the site of a previous aortic cannulation. It was eroding into the sternum (Figs 2A and 2C). Further cardiac surgery was considered a high risk, and she was referred for percutaneous intervention.
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Fig 2. (A) Computed tomographic scan showing pseudoaneurysm from the ascending aorta, eroding the sternum and projecting externally (white arrows). (B) Contrast-enhanced computed tomographic scan showing the Amplatzer muscular ventricular septal defect occluder (AMVO) device (arrow) excluding the aneurysm. (C) Lateral projection angiogram showing the pseudoaneurysm below the innominate artery (black arrows mark the aneurysm neck). (D) Arrows indicate the AMVO device with no opacification of the aneurysm.
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Aortic angiography showed the pseudoaneurysm with the aortic opening measuring 14 mm in diameter. Through a left brachial route, a balloon catheter was placed in the pseudoaneurysm to inflate and occlude the orifice in case of possible rupture of the pseudoaneurysm. An 0.035"-pre-shaped Bentson wire (Cook Inc, Bloomington, IN) was positioned within the pseudoaneurysm and an 18-mm Amplatzer muscular ventricular septal defect occluder (AGA Medical Corp, Plymouth, MN) was delivered through a 10-French torque view sheath at the aortic opening and released. Repeat aortogram and computed tomographic scan showed no residual flow into the pseudoaneurysm (Figs 2B and 2D). She was discharged on 75 mg of aspirin once daily. The pulsatile mass over her chest had completely disappeared 3 months later and she was asymptomatic.
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Comment
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Pseudoaneurysm of the ascending aorta is a rare complication after cardiac surgery, occurring most commonly at the previous cannulation site [1, 4]. Surgery may be associated with high mortality and morbidity and often requires deep hypothermia and circulatory arrest, as these aneurysms are generally adherent to the sternum. In a series of 5 patients, 4 arose from the previous cannulation and 1 from the vein graft sites [4]. Sternotomy resulted in inadvertent rupture of the pseudoaneurysm in 2 patients. Femoro-femoral bypass is a safe and effective method to reduce the risk of rupture during the sternotomy [3].
A percutaneous approach has the advantage of being less invasive and there may be a reduced risk of morbidity and mortality. Exclusion of the pseudoaneurysms arising from the distal aortic arch or the descending aorta may be accomplished by using stent grafts [5]. However, these are not an option for pseudoaneurysms of the ascending aorta because of the large diameter and the proximity of the coronary arteries.
Recently, there have been reports of using Amplatzer septal occluders to exclude pseudoaneurysms from the ascending aorta [6, 7]. Amplatzer septal occluder is used for closing atrial septal defects. The amount of fabric in this device is insufficient to arrest flow across high-pressure chambers. The two discs of the device are asymmetrical in size and will result in the deployment of the larger disc in the pseudoaneurysm, which may injure the wall of the sac. For these reasons, we chose the Amplatzer muscular ventricular septal defect occluder device, because of two equal sized discs. It is essential that the disc at the aortic end should not impinge on the coronary ostia. We showed the feasibility of this procedure from both femoral and brachial routes. Both our patients have had good immediate-term and short-term outcomes.
In conclusion, a transcatheter approach to excluding ascending aortic pseudoaneurysms seems to be a suitable alternative to the surgical management.
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Acknowledgments
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We wish to acknowledge Dr Shippolini and Dr Renfrew for their help in the management of the first case (ie, patient 1).
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References
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- Ramakantan R, Shah P. False aneurysm secondary to aortic cannulation—rupture into lung with fatal hemoptysis during aortography Thorac Cardiovasc Surg 1989;37:322-323.[Medline]
- Dawson D, Clarke NRA, Banning AP. Management of the ascending aortic pseudo-aneurysms—a single centre experience Int J Cardiol 2008;130:92-95.[Medline]
- Smith P, Qureshi S, Yacoub MH. Dehiscence of infected aortocoronary vein graft suture lines. Cause of late pseudoaneurysm of ascending aorta. Br Heart J 1983;50:193-195.[Abstract/Free Full Text]
- Dhadwal AK, Abrol S, Zisbrod Z, Cunningham Jr JN. Pseudoaneurysms of the ascending aorta following coronary artery bypass surgery J Card Surg 2006;21:221-224.[Medline]
- Siddique M, Gupta AK, Thakur RK. Successful exclusion of descending thoracic aortic pseuduaneurysm by endovascular stent-graft placement J Invasive Cardiol 2003;15:597-599.[Medline]
- Bashir F, Quaife R, Carroll JD. Percutaneous closure of ascending aortic pseudoaneurysm using Amplatzer septal occluder device: the first clinical case report and literature review Catheter Cardiovasc Interv 2005;65:547-551.[Medline]
- Kanani RS, Neilan TG, Palacios IF, Garasic JM. Novel use of the Amplatzer septal occluder device in the percutaneous closure of ascending aortic pseudoaneurysms: a case series Catheter Cardiovasc Interv 2007;69:146-153.[Medline]
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Abstract
Introduction
