Endovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft Pseudoaneurysm
2013; Lippincott Williams & Wilkins; Volume: 6; Issue: 1 Linguagem: Inglês
10.1161/circheartfailure.112.971861
ISSN1941-3297
AutoresAsvin M. Ganapathi, Nicholas D. Andersen, Deyanira J. Prastein, Zubair A. Hashmi, Joseph G. Rogers, Carmelo A. Milano, Richard L. McCann, G. Chad Hughes,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoHomeCirculation: Heart FailureVol. 6, No. 1Endovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft Pseudoaneurysm Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBEndovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft Pseudoaneurysm Asvin M. Ganapathi, MD, Nicholas D. Andersen, MD, Deyanira J. Prastein, MD, Zubair A. Hashmi, MD, Joseph G. Rogers, MD, Carmelo A. Milano, MD, Richard L. McCann, MD and G. Chad Hughes, MD Asvin M. GanapathiAsvin M. Ganapathi From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Nicholas D. AndersenNicholas D. Andersen From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Deyanira J. PrasteinDeyanira J. Prastein From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Zubair A. HashmiZubair A. Hashmi From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Joseph G. RogersJoseph G. Rogers From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Carmelo A. MilanoCarmelo A. Milano From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. , Richard L. McCannRichard L. McCann From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. and G. Chad HughesG. Chad Hughes From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC. Originally published1 Jan 2013https://doi.org/10.1161/CIRCHEARTFAILURE.112.971861Circulation: Heart Failure. 2013;6:e16–e18IntroductionA 61-year-old female underwent implantation of a Heartmate II left ventricular assist device (LVAD; Thoratec Corporation, Pleasanton, CA) for end-stage nonischemic cardiomyopathy. Six months later, she presented with chest pain and worsening heart failure symptoms. Computed tomography angiography revealed a large subxiphoid pseudoaneurysm with peripheral thrombus exerting a mass effect on the heart (Figures 1 and 2). Further evaluation by ultrasonography with anterior chest transducer placement confirmed a 13-cm pseudoaneurysm with multiple connections to the LVAD outflow Dacron graft (Figure 3). She was afebrile and had no physical or laboratory evidence of infection. Because of extensive comorbidities, including morbid obesity, restrictive lung disease, and chronic renal insufficiency, open repair via repeat sternotomy was considered risk-prohibitive, and an endovascular repair was pursued.Download figureDownload PowerPointFigure 1. Axial computed tomography angiography image demonstrating the large subxiphoid pseudoaneurysm (red arrow) with area of communication to the outflow graft of the left ventricular assist device (LVAD; yellow arrow).Download figureDownload PowerPointFigure 2. Three-dimensional computed tomography angiography reconstruction demonstrating pseudoaneurysm (yellow arrow) arising from the outflow graft (blue arrow) of the left ventricular assist device (LVAD; red arrow).Download figureDownload PowerPointFigure 3. A, Sagittal ultrasonographic view of the anterior chest demonstrating a 13×9 cm fluid collection (demarcated by + symbols) surrounding the outflow tract (red arrow) from the left ventricular apex (yellow arrow) to the left ventricular assist device (LVAD). B, Sagittal Doppler view demonstrating swirling flow within the fluid collection consistent with pseudoaneurysm.Off-label use of a Gore Excluder (W.L. Gore and Associates, Flagstaff, AZ) iliac limb stent graft (16 mm proximal diameter, 18 mm distal diameter×9.5 cm length) was considered the best commercially available device to attempt endovascular repair. This device was chosen because of the appropriate size match to the Dacron LVAD outflow graft and the short nose of the delivery catheter, which would permit advancement close to the LVAD pump mechanism. Because of a delivery catheter shaft length of only 55 cm, a left axillary artery approach was chosen for device delivery. The left axillary artery was exposed via an infraclavicular incision. An 8 mm Dacron conduit was sewn end-to-side to this artery and brought out through a separate stab incision on the lateral chest to minimize the angle of entry for the wires and sheaths, given patient obesity. Initial attempts at retrograde entry into the LVAD outflow tract from the ascending aorta proved difficult because of high LVAD flow. As such, the decision was made to temporarily turn off the LVAD, after full systemic heparinization to an activated clotting time of greater than 300, which the patient tolerated hemodynamically. An arteriogram of the ascending aorta/arch was then performed, and the location of the distal anastomosis of the LVAD outflow graft identified (Figure 4A) and successfully cannulated using a Cobra-2 catheter (AngioDynamics, Latham, NY), followed by an Amplatz superstiff wire with a 1-cm floppy tip (Cook Medical, Bloomington, IN) that passed into the LVAD outflow graft and down to above the pump portion of the LVAD. An 18-French Gore dry-seal sheath was passed into the LVAD outflow graft over the stiff wire, and a subsequent arteriogram revealed the pseudoaneurysm in the proximal portion of the LVAD outflow graft above the elbow portion of the LVAD (Figure 4A and 4B). The endograft was then deployed with 3 to 4 cm of seal both above and below the location of the pseudoaneurysm. Balloon molding was accomplished with a 16 mm×4 cm angioplasty balloon, and a completion arteriogram demonstrated complete exclusion of the pseudoaneurysm and a well-expanded endograft (Figure 4C and 4D), after which the LVAD was restarted (total LVAD pause time 22 minutes). The patient tolerated the procedure well and was discharged home after treatment of her heart failure exacerbation. Follow-up imaging 6 weeks later demonstrated a well-positioned stent graft without evidence of endoleak and complete resolution of the pseudoaneurysm (Figure 5A through 5C). The patient remains well 10 months postendovascular repair.Download figureDownload PowerPointFigure 4. A, Initial angiography run demonstrating the large pseudoaneurysm (red arrow) at the base of the outflow graft (yellow arrow; ascending aorta indicated by green arrow). B, Fluoroscopy demonstrating wires (yellow arrow) in the left ventricular assist device (LVAD) outflow graft extending into the LVAD apparatus (red arrow). C, Early image of completion angiography run demonstrating contrast in the upper part of LVAD outflow graft within the newly placed endograft (blue arrow). D, Later image of completion run demonstrating good flow through the endograft (yellow arrow) and absence of the blush seen previously within the pseudoaneurysm (red arrow).Download figureDownload PowerPointFigure 5. A, Three-dimensional computed tomography angiography reconstruction image demonstrating the endovascular stent graft in the left ventricular assist device (LVAD) outflow graft. B, Axial computed tomography angiography image showing successful endovascular exclusion of the pseudoaneurysm with no evidence of endoleak. C, Sagittal computed tomography angiography reconstruction image demonstrating the endovascular stent graft in the LVAD outflow graft.DiscussionPseudoaneurysms associated with LVADs are rare, with prior reports of occurrence at the left ventricular apex, as well as the anastamosis of the outflow graft to the ascending aorta.1 Pseudoaneurysm of the LVAD outflow graft, thought to be secondary to graft contact with a sternal wire causing erosion of the graft, was reported in a patient with a Novacor N100 LVAD; this pseudoaneurysm required open repair under deep hypothermia and circulatory arrest.2 Additionally, endovascular repair of a fistula between the outflow graft of a Heartmate II and a portion of the right bronchial tree, with access from the right common carotid artery, has been described.3In the present case, pseudoaneurysm formation could have resulted from prosthetic graft damage during implantation or contact with the sternal wires, as previously described. Additionally, detachment of the bend relief device (Figure 6), which overlies the LVAD outflow graft, could have caused outflow graft damage and pseudoaneurysm formation. To this latter possibility, a recent FDA warning was issued regarding concerns of the bend relief device causing graft obstruction and detachment from the LVAD.4 The endovascular repair strategy described herein represents the second placement of an endovascular stent graft within an LVAD circuit, and the first endovascular repair of an LVAD outflow graft pseudoaneurysm to our knowledge. Potential complications of this repair strategy include endograft infection, potential for LVAD-related thrombus, especially given the temporary cessation of device flow (albeit during a period of full systemic heparinization), damage to the pump mechanism from catheters or wires, wire or catheter entrapment, and endoleak. Lifelong surveillance follow-up imaging is therefore recommended, similar to other endovascular repair procedures. Nonetheless, the endovascular strategy presented seems to represent a novel, safe, and effective treatment for LVAD outflow tract pseudoaneurysm that avoids a highly morbid open operation in a compromised patient population.Download figureDownload PowerPointFigure 6. Image of Thoratec Heartmate II system (http://www.thoratec.com/img/content/sealed-graft-sm.jpg) altered with black arrow to indicate bend relief device. Reprinted with the permission of Thoratec Corporation.Sources of FundingSalary support was provided by a Thoracic Surgery Foundation for Research and Education Research Fellowship (to N.D.A.).DisclosuresDr Hughes is a paid consultant for W.L. Gore and Associates and Terumo Medical. Dr Milano is a paid consultant for Thoratec Corporation. Dr Rogers is a paid consultant for Thoratec Corporation.FootnotesCorrespondence to G. Chad Hughes, MD, Director, Aortic Surgery Program, Duke University Medical Center, Division of Cardiovascular and Thoracic Surgery, Box 3051, Durham, NC 27710. E-mail [email protected]References1. Maeda T, Tanoue Y, Nakashima A, Tominaga R. Atypical presentation of an apical pseudoaneurysm in a patient on prolonged left ventricular mechanical support.Interact Cardiovasc Thorac Surg. 2010; 10:350–351.CrossrefMedlineGoogle Scholar2. Knosalla C, Weng Y, Buz S, Loebe M, Hetzer R. Pseudoaneurysm of the outflow graft in a patient with Novacor N100 LVAD system.Ann Thorac Surg. 2000; 69:1594–1596.CrossrefMedlineGoogle Scholar3. Yanagida R, Kass R, Czer L, Khoynezhad A. Endovascular repair of arterio-bronchial fistula of the outflow graft of HeartMate II left ventricular assist device.J Thorac Cardiovasc Surg. 2011; 142:710–711.CrossrefMedlineGoogle Scholar4. U.S. Food and Drug Administration.Thoratec Corporation, HeartMate II Left Ventricular Assist System (LVAS): Class 1 Recall-Outflow Graft May Kink or Deform.U.S. Food and Drug Administration.April 4, 2012. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm298710.htm. Accessed July 6, 2012.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByShahbahrami K, Lee C and Tsukashita M (2023) Mycotic Left Ventricular Apical Pseudoaneurysm Following HM3 Left Ventricular Assist Device Implantation, Circulation: Cardiovascular Imaging, 16:1, (e014278), Online publication date: 1-Jan-2023. Balceniuk M, Ziazadeh D, Mix D, Prasad S and Stoner M (2020) Totally percutaneous endovascular repair of HeartMate 3 ventricular assistive device outflow graft pseudoaneurysm, Journal of Vascular Surgery Cases, Innovations and Techniques, 10.1016/j.jvscit.2020.09.001, 6:4, (505-508), Online publication date: 1-Dec-2020. Teman N, Shah S, Downs E, Ailawadi G, Mazimba S, Fritz Angle J, Khaja M and Yarboro L (2020) Endovascular repair of left ventricular assist device outflow graft defect, Journal of Cardiac Surgery, 10.1111/jocs.15005, 35:11, (3235-3238), Online publication date: 1-Nov-2020. Pya Y, Mussayev A, Alimbayev S, Medressova A, Bekbossynov S, Andossova S, Khissamutdinov N, Jetybayeva S and la Fleur P (2020) Left Ventricular Assist Device Outflow Graft Pseudoaneurysm Treated with Covered Balloon Expandable Stent, ASAIO Journal, 10.1097/MAT.0000000000001033, 66:5, (e74-e76), Online publication date: 1-May-2020. Alnabelsi T, Shafii A, Gurley J, Dulnuan K, Harris II D and Guglin M (2019) Left Ventricular Assist Device Outflow Graft Obstruction: A Complication Specific to Polytetrafluoroethylene Covering. A Word of Caution!, ASAIO Journal, 10.1097/MAT.0000000000000929, 65:6, (e58-e62), Online publication date: 1-Aug-2019. Ahmad F, Sauer A and Ricciardi M (2016) Endovascular repair of ventricular assist device outflow cannula stenosis, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26852, 91:7, (E81-E85), Online publication date: 1-Jun-2018. Trankle C, Quader M, Grizzard J, Tang D, Shah K, Paris K, Shepard C and Gertz Z (2018) Internal Versus External Compression of a Left Ventricular Assist Device Outflow Graft, Circulation: Heart Failure, 11:5, Online publication date: 1-May-2018. Hubbert L, Forssell C, Baranowski J, Lindgren B, Holm J and Ahn H (2017) Endovascular Stenting of a LVAD Outflow Graft Thrombosis, ASAIO Journal, 10.1097/MAT.0000000000000371, 63:1, (e3-e5), Online publication date: 1-Jan-2017. Cho S, Fritz T and Khaghani A (2016) Traumatic pseudoaneurysm resulting from ruptured outflow graft due to disconnection of HeartMate II LVAD Bend Relief, Journal of Cardiology Cases, 10.1016/j.jccase.2016.02.001, 13:6, (178-180), Online publication date: 1-Jun-2016. Mallidi H, Anand J and Singh S (2015) Long-term mechanical circulatory support: A new disease state?, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2015.04.049, 150:1, (e13-e14), Online publication date: 1-Jul-2015. Abraham J, Remick J, Caulfield T, Puhlman M, Evenson K, Ott G and Kirker E (2015) Left Ventricular Assist Device Outflow Cannula Obstruction Treated With Percutaneous Endovascular Stenting, Circulation: Heart Failure, 8:1, (229-230), Online publication date: 1-Jan-2015. Dhesi P, Sadiq I and Gluck J (2014) Endovascular repair of a HeartMate II left ventricular assist device, The Journal of Heart and Lung Transplantation, 10.1016/j.healun.2014.09.001, 33:11, (1198-1199), Online publication date: 1-Nov-2014. Partyka C and Taylor B (2014) Review article: Ventricular assist devices in the emergency department, Emergency Medicine Australasia, 10.1111/1742-6723.12171, 26:2, (104-112), Online publication date: 1-Apr-2014. January 2013Vol 6, Issue 1 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.112.971861PMID: 23322880 Manuscript receivedSeptember 5, 2012Manuscript acceptedNovember 6, 2012Originally publishedJanuary 1, 2013 Keywordsaneurysmventricular assist devicecardiomyopathyPDF download Advertisement
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