Abstract
Iatrogenic ascending aortic pseudoaneurysms are a rare but life-threatening complication of reconstructive cardiovascular surgery. Such aneurysms can result in rupture, thrombosis, or distal embolization. Surgical repair of such pseudoaneurysms is associated with high morbidity and mortality. We present a rare case of device closure of saccular pseudoaneurysm of the ascending aorta in a patient with valve-sparing Bentall surgery for acute type A aortic dissection.
Key words: ascending aorta pseudo-aneurysm, device closure, iatrogenic pseudo-aneurysm, post Bentall aortic pseudoaneurysm
Graphical Abstract
Pseudoaneurysms represent a collection of blood between the adventitia and media resulting from a disruption in the aortic wall. Iatrogenic ascending aortic pseudoaneurysms are a rare but life-threatening complication of reconstructive cardiac surgery. They can occur at the cannulation site, clamping site, or graft anastomosis site.1 Such aneurysms are predisposed to rupture, thrombosis, and distal embolization. Open surgical repair is considered standard of care but can be difficult and has substantial morbidity and mortality reaching up to 21% in specific patients.2 If preprocedural imaging demonstrates suitable anatomy, direct transcatheter closure with a device offers a minimally invasive approach which obviates the need of landing zones for a stent graft. In this report, we describe successful transcatheter closure of technically challenging case of ascending aortic pseudoaneurysm with a Konar MF ventricular septal defect closure device. To our knowledge, this is the first such case where Konar MF device is used for pseudoaneurysm closure.
History of Presentation and Past Medical History
This is a case of a 51-year-old male with a past medical history of acute coronary syndrome with inferior wall myocardial infarction, undergone thrombolysis with Reteplase. Coronary angiogram showed mid-right coronary artery (RCA) 90% thrombotic occlusion, distal RCA 80% lesion, and mid-left anterior descending artery (LAD) 70% disease. Successful percutaneous transluminal coronary angioplasty (PTCA) to RCA was done, and staged PTCA to LAD was advised. The patient presented to the hospital with chest pain after 2 days of discharge. Check angiogram showed patent stent in RCA and ascending aortic dissection from RCA injection from right sinus extending up to arch. CT aortogram showed type A dissection of aorta extending till the abdominal aorta (Figure 1). Successful valve-sparing Bentall surgery with aortic root replacement with a 26-mm Dacron graft and coronary artery bypass grafting with 3 grafts (left internal mammary artery to LAD, saphenous vein graft to posterior descending artery, and acute marginal) was done. After recovering from surgery, he remained asymptomatic for 20 months.
Figure 1.
Ascending Aorta Dissection
Computed tomography aortogram in axial section showing aortic dissection involving the ascending aorta and the descending aorta (blue arrows).
Differential Diagnosis
Follow-up CT aortogram showed saccular pseudoaneurysm measuring 6.06 × 6.47 × 3.59 cm with a patent lumen of 3 × 2.2 × 3.1 cms at the distal graft anastomosis with the ascending aorta (Figure 2). All major branches of the arch of aorta are patent and arising from true lumen. A persistent dissection flap in the descending aorta till the abdominal aorta was noticed.
Figure 2.
Follow-Up CT With Psuedoaneurysm
Follow-up computed tomography aortogram in sagittal section showing saccular pseudoaneurysm from the ascending aorta (green arrow) and persistence of dissection distal to left subclavian artery.
Management
After a discussion in the heart team, the patient was taken up for device closure of saccular pseudoaneurysm as the neck of aneurysm is narrow and coronaries are well away from the neck (Figure 3). Right femoral arterial access was taken with a 7-F sheath, and 7-F, 3.5 JR was advanced into the abdominal aorta. Catheter position in true lumen was confirmed with an aortic injection, and the catheter was advanced into the ascending aorta. Pigtail injection was taken in the ascending aorta, and the neck of the pseudoaneurysm was identified (Figure 4). It was engaged with 3.5 JR (Figure 5) as it was the most suitable one to place it as coaxial as possible with the neck of the pseudoaneurysm, and a 10 × 8 mm Konar MF (Life Tech Scientific) device was deployed across the neck of aneurysm (Figure 6). Aortic root angiography showed no contrast flow into the pseudoaneurysm (Figure 7).
Figure 3.
CT Aortogram: Aneurysm to RCA Distance
CT aortogram showing the RCA distance (23 mm) from the neck of pseudoaneurysm. The red arrow indicates RCA origin. RCA = right coronary artery.
Figure 4.
Aortogram With Psuedoaneurysm
Aortogram with a pigtail catheter in the ascending aorta filling the pseudoaneurysm (indicated by a star).
Figure 5.
JR Catheter With in Pseudoaneurysm
JR catheter engaged into the neck of pseudoaneurysm.
Figure 6.
Konar MFO Across Neck of Pseudoaneurysm
Konar MFO device deployed across the neck of pseudoaneurysm (Konar MFO device indicated by arrow).
Figure 7.
Final Aortogram After Closure
DSA with pigtail catheter in ascending aorta showing no shunt across the Konar MFO device (Konar device indicated by a blue arrow).
Outcome and Follow-Up
There were no procedural complications, and the patient was discharged after 48 hours. Follow-up CT aortogram after 1 month showed an in situ device with no contrast enhancement of pseudoaneurysm (Figure 8).
Figure 8.
Follow-Up CT Device Closure
CT aortogram on follow-up showing Konar MFO device in the neck pseudoaneurysm with complete thrombosis (Konar device indicated by a blue arrow. (A) Sagittal view; (B) axial view.
Discussion
Pseudoaneurysms of ascending aorta are a rare complication of cardiac surgery, thoracic surgery, or trauma. Surgical repair is the most common treatment for pseudoaneurysm but is associated with high morbidity and mortality. Percutaneous techniques such as stent graft, coil embolization, and thrombin injection into the pseudoaneurysm have also been described in cases with suitable anatomy.3 There are few reports demonstrating successful closure of the noninfective pseudoaneurysms with a short neck and positioned away from vital arterial branches by percutaneous approach using an occluder device. Stasek et al4 demonstrated that closure is possible and associated with acceptable long-term prognosis in 2 years of follow up. Most of the data in literature described usage of an Amplatzer atrial septal occluder device and an Amplatzer muscular ventricular septal defect device to seal the pseudoaneurysm.5 This case report demonstrates successful use of a Konar MFO device (a multifunctional occluder device, Life Tech Scientific) in the treatment of large pseudoaneurysm of the ascending aorta. The Konar MFO (Figure 9) is a double-disk device, with the second disk attached to the body by a small cone-shaped connection. It can be screwed onto the delivery cable from either side, hence allowing deployment in both directions. Konar MFO can be delivered through a JR catheter and does not require a sheath as in the case of the Amplatzer septal occluder device. Delivering a sheath into ascending aorta aneurysm across arch angulation has consequences, although rare. Device deliverable through a guide catheter would ease the complexity and minimize complications.
Figure 9.
Konar MFO Device
To our knowledge, this is the first description of a Konar MF device used for this indication. Further experience is needed with this device in such scenarios.
Conclusions
Open surgical repair of saccular pseudoaneurysm is the recommended treatment option for patients with acceptable surgical risk. In high-risk patients with suitable anatomy, a percutaneous approach can be considered. Interventional closure of ascending aortic pseudoaneurysm with a Konar MF device, which can be delivered through a guide catheter, is a good alternative to the Amplatzer septal occluder. Further experience is needed with this device for this purpose.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Take-Home Messages
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Pseudoaneurysm of the aorta with a short neck can be amenable to percutaneous closure with devices.
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Konark MF device, which can be delivered through the guide catheter, would ease the procedure.
Acknowledgment
The author would like to acknowledge Dr Chandana Poosala for drafting the manuscript.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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