Transcatheter Closure of Complex Ascending Aortic Pseudoaneurysms After Cardiac Surgery
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 9 Linguagem: Inglês
10.1161/circinterventions.118.007052
ISSN1941-7632
AutoresLiang Tang, John R. Lesser, Mario Gössl, Marcus Burns, Lynelle Schneider, Jonathan Schwartz, Hiroki Niikura, Desmond Jay, Paul Sorajja,
Tópico(s)Infectious Aortic and Vascular Conditions
ResumoHomeCirculation: Cardiovascular InterventionsVol. 11, No. 9Transcatheter Closure of Complex Ascending Aortic Pseudoaneurysms After Cardiac Surgery Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBTranscatheter Closure of Complex Ascending Aortic Pseudoaneurysms After Cardiac SurgeryA Multimodality Imaging Approach Liang Tang, MD, John R. Lesser, MD, Mario Gössl, MD, PhD, Marcus R. Burns, DNP, Lynelle M. Schneider, PA, Jonathan G. Schwartz, MD, Hiroki Niikura, MD, Desmond B. Jay, MD and Paul Sorajja, MD Liang TangLiang Tang Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China (L.T.). , John R. LesserJohn R. Lesser Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Mario GösslMario Gössl Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Marcus R. BurnsMarcus R. Burns Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Lynelle M. SchneiderLynelle M. Schneider Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Jonathan G. SchwartzJonathan G. Schwartz Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Hiroki NiikuraHiroki Niikura Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). , Desmond B. JayDesmond B. Jay Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). and Paul SorajjaPaul Sorajja Paul Sorajja, MD, Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E 28th St, Suite 200, Minneapolis, MN 55407. Email E-mail Address: [email protected] Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., J.R.L., M.G., M.R.B., L.M.S., J.G.S., H.N., D.B.J., P.S.). Originally published12 Sep 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007052Circulation: Cardiovascular Interventions. 2018;11:e007052Ascending aortic pseudoaneurysm is a rare, yet life-threatening complication of reconstructive cardiac surgery, trauma, or infection.1 Such aneurysms are predisposed to rupture, thrombosis, and distal embolization.2 Surgical repair of pseudoaneurysm is often considered but is associated with high mortality and morbidity.3,4 As an alternative, transcatheter closure may be an effective treatment in selected patients.1–4 In this report, we describe successful transcatheter closure of 2 technically challenging cases of ascending aortic pseudoaneurysm. These cases illustrate a multimodality imaging approach, as well as novel interventional techniques that facilitate procedure success.Case 1A 78-year-old woman was admitted with sudden onset of progressively worsening shortness of breath and substernal pain radiating to her upper back and jaw. Five months before admission, she had undergone emergent surgical repair of an acute type A aortic dissection repair with a 30-mm Hemashield graft and concomitant aortic valve replacement with a 21-mm Edwards Magna valve. One month later, repeat surgery with replacement of her aortic hemiarch also was required. After this last surgery, the postoperative period was complicated by a chest wall abscess and mediastinitis, requiring sternal wound debridement and wound vacuum-assisted closure placement, with cultures growing Coagulase-negative staphylococci and Klebsiella. Her past medical history also was notable for deep vein thrombosis and pulmonary embolism, atrial fibrillation, and prior stroke.On admission, transesophageal echocardiogram (TEE) revealed a large anterior pseudoaneurysm originating from the aortic root, with neck of 10 mm and approximate dimensions of 5.5×4.5 cm. There was pulsatile flow between the aortic root and the pseudoaneurysm (Figure 1A; Movie I in the Data Supplement). Chest computed tomography showed an extremely tortuous aorta and an anteriorly located, huge saccular pseudoaneurysm, which was causing partial compression of the distal aorta and carina (Figure 1B). Given her general frailty, multiple prior surgeries and their complications, the patient was considered to be at prohibitive operative risk. After a full heart team discussion, a percutaneous approach was undertaken.Download figureDownload PowerPointFigure 1. Transcatheter closure of an enormous ascending aortic pseudoaneurysm (PSA) after aortic valve replacement and aortic dissection repair.A, Transesophageal echocardiogram (TEE) showed a large PSA originating from the aortic root with characteristic to and fro flow in the communicating tract. B, Computed tomography scan in sagittal view demonstrated an enormous saccular PSA arising from the anterior ascending aorta with a neck measuring ≈12 mm. C, Ascending aortogram in right anterior oblique view showed a pulsatile mass corresponding to a PSA (arrowhead). D, An 8F shuttle sheath was advanced over a 5F multipurpose (MP, arrowhead) catheter crossing the defect into the aneurysm. E, Injection through the sheath demonstrated opacification of the PSA. F, Repeat TEE after device closure of the PSA confirmed no obvious residual shunting. G, Final aortogram showed a well-placed Amplatzer Septal Occluder (ASO, arrowhead) in the neck of the PSA with no significant residual flow. H, Transthoracic echocardiography performed on the following day confirmed the ASO effectively closed the pseudoaneurysm. AAO indicates ascending aorta.The patient was brought to a hybrid operating room and placed under general anesthesia. Ascending aortography showed a pulsatile mass corresponding to the pseudoaneurysm (Figure 1C; Movie II in the Data Supplement). Under TEE and fluoroscopic guidance, the pseudoaneurysm was selectively engaged with a 6F Judkins right catheter and 0.018″ Glidewire (Terumo, Somerset, NJ). Over the Glidewire, a 3.1F Quick-Cross support catheter (Spectranetics, Colorado Springs, CO) was inserted into the pseudoaneurysm, followed by exchange for a 260-cm (pre-shaped with multiple curves) Super Stiff wire (Boston Scientific, Natick, MA). Next, an 8F Shuttle sheath (Cook Medical, Bloomington, IN) was advanced into the pseudoaneurysm. However, the dilator would not allow us to pass into the aneurysm because of its significant stiffness. We then removed the dilator and telescoped a 5F multipurpose catheter inside the Shuttle sheath, which was then placed into the pseudoaneurysm (Figure 1D). Injection through the sheath demonstrated opacification of the pseudoaneurysm (Figure 1E). A 16-mm Amplatzer Atrial Septal Occluder (Abbott Vascular, Santa Clara, CA) was successfully deployed across the defect opening. Repeat TEE and ascending aortography showed a well-seated device with no evidence of significant residual shunting (Figure 1F and 1G; Movies III and IV in the Data Supplement), and these findings were confirmed with postoperative transthoracic echocardiography (Figure 1H). Postprocedurally, however, she had chest pain with evidence of ongoing infective aortitis. Repeat multidetector computed tomography performed 5 days after the procedure showed that a 5-mm communication to the pseudoaneurysm. She ultimately underwent an attempt at aortic root replacement and hemiarch reconstruction but could not come off cardiopulmonary bypass and expired.Case 2A 51-year-old man presented with a history of 3 prior sternotomies for aortic valve disease, in the setting of prior mantle chest radiation for Hodgkin's lymphoma. At his last surgery, the aortic valve was re-replaced with an 18-mm mechanical ATS prosthesis for severe paravalvular regurgitation, and a root enlargement was attempted but not possible because of severe calcification. Endarterectomy was performed to remove massive calcific shelves throughout the ascending aorta and proximal aortic arch. He was also known to have radiation-induced, severe restrictive lung disease, chronic anemia, severe tricuspid regurgitation, and paroxysmal atrial fibrillation.On admission, TEE showed an enormous pseudoaneurysm superior to the aortic valve prosthesis with systolic pulsatile flow from the aorta into the pseudoaneurysm cavity (Figure 2A; Movie V in the Data Supplement). Chest computed tomography confirmed the pseudoaneurysm, which measured 9.0×7.7 cm in the mediastinum, surrounded a heavily calcified aorta, and was partially compressing the right ventricular outflow tract (Figure 2B and 2C). Given his frailty, multiple prior surgeries, and their complications, the patient was considered to be at prohibitive risk of repeat surgery, and percutaneous closure was undertaken.Download figureDownload PowerPointFigure 2. Transcatheter closure of multiple ascending aortic pseudoaneurysm (PSA) after aortic valve replacement (Part I).A, Transesophageal echocardiogram (TEE) showed an enormous PSA with pulsatile flow from the aorta into the cavity. Chest computed tomography with transverse (B) and (C) sagittal view revealed an enormous PSA in the mediastinum that surrounded a porcelain aorta and partially compressing the right ventricular outflow tract. D, Ascending aortography identified the PSA arising from the right anterior portion of the aorta. E, The PSA was engaged with a 6F Judkins right coronary guide catheter, followed by passage of a 0.014″ coronary guidewire (arrow) and a Quick-cross catheter (QC, arrowhead). F, An 18-mm Amplatzer septal occluder (arrowhead) was successfully deployed across the defect. G and H, Repeat TEE and aortogram identified a separate second defect. AAO indicates ascending aorta; AV, aortic valve; RV, right ventricular; and RVOT, right ventricular outlet tract.Ascending aortography demonstrated the pseudoaneurysm arising from the right anterior portion of the aorta (Figure 2D; Movie VI in the Data Supplement). Under TEE and fluoroscopic guidance, the pseudoaneurysm was selectively engaged with a 6F Judkins right coronary guide catheter, followed by passage of a 0.014″ coronary guidewire (arrow, Figure 2E). Sequentially, we then used a 1.8F Quick-Cross catheter (arrowhead, Figure 2E) to exchange for a 0.018″ Glidewire, 3.1F Quick-Cross catheter, and a 0.035″ Glidewire, which was used to pass a 9F Shuttle sheath (Cook Medical, Bloomington, IN) into the pseudoaneurysm. The sheath facilitated placement of an 18-mm Amplatzer Atrial Septal Occluder (Abbott Vascular, Santa Clara, CA; Figure 2F). At the time of this placement, however, repeat TEE and aortography (Figure 2G and 2H; Movies VII and VIII in the Data Supplement) identified another communication between the aorta and the pseudoaneurysm. Our initial attempts to wire this second opening into the pseudoaneurysm were not successful, and we aborted the procedure to have the patient undergo a chest computed tomography study. The computed tomography demonstrated the second defect originating from the posterior lateral aspect of ascending aorta and provided angles for imaging intensifier that would facilitate engagement of defect (right anterior oblique 27°, cranial 0°; Figure 3A). Using these angles, and with TEE and fluoroscopic guidance, this second defect of pseudoaneurysm was selectively engaged and treated in similar fashion with a 6F Judkins right coronary catheter, a 0.014″ Whisper coronary guidewire, an exchange over a 0.018″ Glidewire for a 4F Shuttle sheath, followed by placement of an 8-mm Amplatzer Vascular Plug II (Abbott Vascular, Santa Clara, CA; Figure 3B). Final aortogram and TEE showed well-seated devices with minimal residual leak (Figure 3C and 3D; Movies IX and X in the Data Supplement). The patient was discharged after uncomplicated hospital stay. Five months later, he was rehospitalized for heart failure because of severe tricuspid regurgitation. Repeat TEE showed stable Atrial Septal Occluder and Amplatzer Vascular Plug devices without residual flow. Transcatheter tricuspid valve repair was attempted with MitraClip but was unsuccessful. The patient died 1 month later.Download figureDownload PowerPointFigure 3. Transcatheter closure of multiple ascending aortic pseudoaneurysm (PSA) after aortic valve replacement (Part II). A, Chest computed tomography clearly delineated the other pseudoaneurysm (PSA) originating from the posterior aspect of ascending aorta (arrowhead). B, An 8-mm Amplatzer Vascular Plug (AVP) II is placed across the neck of the second PSA (arrow). C, Final aortogram showed no significant residual shunt. D, Repeat transesophageal echocardiogram demonstrated complete exclusion of the 2 PSAs. AAO indicates ascending aorta; ASO, Amplatzer septal occluder; and RAO, right anterior oblique.DiscussionAscending aortic pseudoaneurysms may occur at the site of a graft anastomosis, aortotomy, or cannulation and are associated with a high risk of rupture, thrombosis, and death if left untreated.2,3 Thus, aggressive treatment should be considered even though surgery may be technically challenging. For those in whom conventional surgery cannot be performed or patients where a less invasive option is desired, catheter-based treatment can be undertaken as a life-saving treatment.1–4 Given the rarity of its occurrence, the experience of percutaneous closure of ascending aortic pseudoaneurysm is limited. Appropriate planning, multimodality imaging, and an individualized approach to treatment proved essential to the procedure with an excellent outcome. Technically challenging aortic pseudoaneurysms can be approached with catheters and wires conventionally used in interventional cardiology. The use of soft coronary guidewires enhances steering of the catheter for engagement of the defects. Once the pseudoaneurysm is cannulated, a step-up approach for placing stiffer guidewires is used with exchange catheters, followed by placement of a variety of delivery catheters for deployment of occluders. The 3-dimensional printing technology has recently been introduced for complex structural interventions. This technology is helpful for anatomic assessment and preprocedural planning. However, our cases demonstrated that procedure success was possible through comprehensive imaging. Complete closure is essential for pseudoaneurysm therapy, as persistent residual flow will cause the pseudoaneurysm to remain patent. Caution should be exercised in patients with suspected infective aortitis. Nonetheless, these techniques may offer alternative life-saving or palliative treatment in patients who are deemed inoperable of reoperative surgery.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCINTERVENTIONS.118.007052.https://www.ahajournals.org/journal/circinterventionsPaul Sorajja, MD, Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E 28th St, Suite 200, Minneapolis, MN 55407. Email paul.[email protected]comReferences1. Hussain >J, Strumpf >R, Wheatley >G, Diethrich >E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-case series of six patients.Catheter Cardiovasc Interv. 2009; 73:521–529. doi: 10.1002/ccd.21833CrossrefMedlineGoogle Scholar2. 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. doi: 10.1002/ccd.20794CrossrefMedlineGoogle Scholar3. Lyen >SM, Rodrigues >JC, Manghat >NE, Hamilton >MC, Turner >M. Endovascular closure of thoracic aortic pseudoaneurysms: a combined device occlusion and coil embolization technique in patients unsuitable for surgery or stenting.Catheter Cardiovasc Interv. 2016; 88:1155–1169. doi: 10.1002/ccd.26558CrossrefMedlineGoogle Scholar4. Kumar >PV, Alli >O, Bjarnason >H, Hagler >DJ, Sundt >TM, Rihal >CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms.Catheter Cardiovasc Interv. 2012; 80:687–699. doi: 10.1002/ccd.24300CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 2018Vol 11, Issue 9 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007052PMID: 30354597 Originally publishedSeptember 12, 2018 Keywordsaortic rupturepseudoaneurysmcatheterizationcardiac surgeryPDF download Advertisement SubjectsTreatment
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