Transesophageal Echocardiography Guidance for Percutaneous Closure of Ascending Aortic Pseudoaneurysm.

Transesophageal Echocardiography Guidance for Percutaneous Closure of Ascending Aortic Pseudoaneurysm Carola Maraboto Gonzalez, MD, Neel Butala, MD, Nilay K. Patel, MD, Ignacio Inglessis-Azuaje, MD, Arminder S. Jassar, MBBS, and Evin Yucel, MD, Boston, Massachusetts INTRODUCTION A pseudoaneurysm is a focal arterial outpouching resulting from an injury to the vascular wall, which leads to a contained rupture with a collection of blood between the media and the adventitia.1 Although it is unusual to find pseudoaneurysms in the ascending aorta, this particular location represents a potentially life-threatening condition as it is associated with an increased risk of thrombosis, embolization, and even complete arterial rupture.2 Unfortunately, there are no clinical or imaging features that can accurately predict such catastrophic complications, and, therefore, aggressive treatment is recommended.3,4 Currently, surgical repair holds its place as the standard of care and is the preferred treatment for most patients, but it can be technically challenging and carries significant risk in some cases.5 This has led to the development of several endovascular techniques, and percutaneous closure of ascending aortic pseudoaneurysms has been successfully performed in selected patients with high surgical risk.4,6 For these cases, a multidisciplinary discussion with multimodality imaging is critical to plan the interventional approach and avoid procedural complications.7,8 While transesophageal echocardiography (TEE) is traditionally considered a secondary and optional imaging mode during these procedures, it can be a valuable tool and serve as the primary intraprocedural imaging modality in specific cases. CASE PRESENTATION A 52-year-old woman was referred for treatment of chronic sternal osteomyelitis and ascending aortic pseudoaneurysm after coronary artery bypass graft surgery (CABG). The patient’s medical history was also notable for chronic kidney disease associated with left renal atrophy due to severe renal artery stenosis. With the diagnosis of ascending aortic pseudoaneurysm, first noted 3 months after CABG, serial computed tomography (CT) scans were done and reported stable size for several months. However, around From the Echocardiography Laboratory, Division of Cardiology (C.M.G., E.Y.); Division of Cardiology (N.B., N.K.P., I.I.-A.), and Division of Cardiac Surgery (A.S.J.), Massachusetts General Hospital, Boston, Massachusetts. Keywords: Pseudoaneurysm, Percutaneous, Transesophageal echocardiography, Intraprocedural, Ascending aorta Correspondence: Evin Yucel, MD, MSc, FACC, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, Massachusetts 02114. (E-mail: EYUCEL@ PARTNERS.ORG). Copyright 2022 by the American Society of Echocardiography. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). 2468-6441 https://doi.org/10.1016/j.case.2022.09.009 8 months after the initial diagnosis, the surveillance scan suggested an increase in the pseudoaneurysm size associated with surrounding soft tissue thickening and sternal osteomyelitis (Figure 1). These findings raised concern regarding the potential risk of rupture, and the patient was referred to our institution for further evaluation and management. A multidisciplinary heart team discussion was held, and while it was believed that surgery would be required for further debridement, the risk of a surgical intervention was considered high in the setting of aortitis and active infection. One critical factor was the presence of an in situ right internal mammary artery graft to the left anterior descending artery, with the graft coursing anterior to the aorta, adjacent to the pseudoaneurysm and just underneath the sternum (Figure 2); therefore, an open approach would carry a high risk of graft injury. In this regard, the possibility of percutaneous coronary intervention was discussed in case the graft needed to be sacrificed; however, the patient’s coronary anatomy was not optimal for this. Moreover, waiting for the ideal time for surgery would pose a risk of pseudoaneurysm rupture and potentially devastating consequences. After a careful evaluation, the decision was made to attempt a percutaneous closure with fluoroscopy and TEE guidance to avoid the administration of a large amount of iodinated contrast during the procedure given the renal disease. Since the pseudoaneurysm was located in the distal ascending aorta, a high upper esophageal view was required to keep it in the view (Figure 3). By TEE, the pseudoaneurysm had a neck of 7  8 mm and the sac measured 31  26  18 mm, with a partially thrombosed cavity (Figure 4, Video 1). Of note, measurements of the pseudoaneurysm size were consistent among CT, TEE, and fluoroscopy. Pulsed-wave Doppler at the neck of the lesion demonstrated bidirectional flow, consistent with the ‘‘to-and-fro’’ pattern classically seen in pseudoaneurysms (Figure 5). Under TEE guidance, a delivery catheter with a 6-4 Amplatzer Duct Occluder II, which has 12 mm disks, was placed at the neck of the pseudoaneurysm (Figure 6, Videos 2 and 3). Initial placement appeared adequate angiographically, but TEE highlighted that a portion of the aortic disk may have been deployed into the pseudoaneurysm neck (Video 4), prompting us to reposition the device and deploy once properly placed. At the end of the procedure, the device appeared well seated, with a slight disk motion from compression of the nitinol wire mesh by the systolic aortic movement, which is an expected finding (Videos 5 and 6). The pseudoaneurysm cavity was almost completely thrombosed (Figure 7, Videos 5 and 6), and there was no significant residual leak noted by TEE, although fluoroscopy demonstrated a faint amount of contrast inside the pseudoaneurysm sac, suggesting a trivial leak (Figure 8, Video 7). In addition, a small mobile echodensity was noted on the aortic surface of the device, which was thought to be consistent with thrombus (Videos 5 and 6). Initiation of therapeutic anticoagulation was discussed, but given the small size and the impending need for surgical intervention, it was decided to manage this with aspirin alone. The patient underwent sternal debridement a few days later, 21 22 Maraboto Gonzalez et al CASE: Cardiovascular Imaging Case Reports January 2023 VIDEO HIGHLIGHTS Video 1: Intraprocedural TEE images showing the ascending aorta and the pseudoaneurysm in short axis from an upper esophageal view. To the left, the two-dimensional mode shows the location of the PSA; to the right, color Doppler reveals flow into the PSA cavity, which is partially thrombosed. Video 2: Intraprocedural TEE images showing the ascending aorta and the pseudoaneurysm in long axis from an upper esophageal view. To the left, two-dimensional mode with delineation of the PSA and the catheter; to the right, color Doppler enhances the demarcation of (...truncated)