Direct percutaneous transaortic approach for treatment of aortic pseudoaneurysms

CASE REPORT – ADULT CARDIAC Interactive CardioVascular and Thoracic Surgery 20 (2015) 680–681 doi:10.1093/icvts/ivv027 Advance Access publication 23 February 2015 Cite this article as: Pirelli L, Kliger C, Fontana GP, Ruiz CE. Direct percutaneous transaortic approach for treatment of aortic pseudoaneurysms. Interact CardioVasc Thorac Surg 2015;20:680–1. Direct percutaneous transaortic approach for treatment of aortic pseudoaneurysms Luigi Pirelli, Chad Kliger, Gregory P. Fontana and Carlos E. Ruiz* Lenox Hill Heart and Vascular Institute of New York, New York, NY, USA * Corresponding author. Lenox Hill Heart and Vascular Institute of New York, 100 East 77th Street, Black Hall 9th Floor, New York, NY 10075, USA. Tel: +1-212-4343000; fax: +1-212-4342193; e-mail: (C.E. Ruiz). Abstract Aortic pseudoaneurysms (APAs) can develop months or years after aortic and cardiac surgery. If not treated appropriately, APAs can lead to fatal complications and ultimately death. We describe a case of a 61-year old patient with a diagnosed large pseudoaneurysm 5 years after his aortic valve surgery, who was treated with a novel transcatheter direct transaortic approach. The patient had dilated cardiomyopathy with an APA adjacent to the lower sternal plate. An Amplatzer septal occlusion device followed by coils was delivered transcutaneously through the APA to close its neck and fill the false aneurysm, respectively. Triple fusion multimodality imaging was used to guide the placement of the occlusion devices. The merging of computed tomography (CT) and echocardiography with real-time fluoroscopy was fundamental in procedural planning and guidance. Post-procedural transoesophageal echocardiogram (TOE) and CT angiography showed complete exclusion of the APA. A direct transaortic approach is a valid option for closure of an APA if the surgical risk is prohibitive, and the use of triple fusion technology is an essential tool in the hands of interventionalists and surgeons for preoperative planning and conduction of these procedures. Keywords: Aortic aneurysm • Aortic operation INTRODUCTION Aortic pseudoaneurysms (APAs) are a rare, yet potentially lifethreatening complication after cardiac or aortic surgery [1]. Left untreated, ascending APAs can rupture or lead to mass effects within the anterior mediastinum. Historically, resternotomy, cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) with selective cerebral perfusion have been the standard techniques utilized to safely re-enter the chest and replace the involved segment of ascending aorta [2]. These procedures, commonly performed in high-risk patients with multiple comorbidities and previous operative interventions, portend a significant morbidity and mortality. Transcatheter-based interventions can be a potential alternative when surgical risks are prohibitive [3]. This case demonstrates a unique percutaneous transaortic approach of APA closure when a more conventional retrograde trans-femoral technique cannot be performed. MATERIALS AND METHODS We describe a 61-year old male with a history of previous aortic valve replacement in 2008, complicated by emergency re-exploration for bleeding originating from the aortotomy suture line. A bovine pericardial patch was sutured in place and bleeding contained. With time, a pseudoaneurysm of the ascending aorta originating at the level of the aortic suture line developed. The patient had nonischaemic dilated cardiomyopathy with an estimated left ventricular ejection fraction of 15% and presented with congestive heart failure (New York Heart Association III) and haemoptysis. A bronchoscopy did not reveal any respiratory tract anomaly. Structural chest computed tomography angiography (CTA) showed a large pseudoaneurysm with calcified walls anterior to the ascending aorta, measuring 9.8 × 7.6 cm, adjacent to the sternum (Fig. 1A). The ostium of the APA measured 2.7 cm and its distance from the right coronary artery (RCA) was 10.7 mm. TOE confirmed these findings as well as a large intramural thrombus. The patient was deemed too high-risk for surgical correction due to his previous surgical history, defect anatomy and low ejection fraction. Chest re-entry carries a significant risk of injury to the aorta and right ventricle when adherent to the sternum. A safe surgical approach should contemplate establishment of peripheral CPB and HCA with selective cerebral perfusion, to avoid APA injury and fatal bleeding. This option was considered extremely dangerous due to decreased left ventricle function and difficulty weaning from CPB. The proximity of the lower rim of the aneurysm to the coronary ostia made the use of a vascular endostent unfeasible. After discussion with the patient, a decision was made to attempt transcatheter exclusion of the false aneurysm with an off- © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Received 22 October 2014; received in revised form 12 January 2015; accepted 23 January 2015 L. Pirelli et al. / Interactive CardioVascular and Thoracic Surgery 681 DISCUSSION APAs are rare complications of aortic or heart surgery that can manifest a long time after the operation. If not operated upon, an APA can continue to expand, ultimately leading to rupture and death. Reoperation in patients with significant surgical history and comorbidities may be problematic: proximity of the APA to the chest wall during redo sternotomy by itself carries a high surgical risk; moreover, complex procedures with long CPB times and HCA with cerebral perfusion are frequently needed to perform the operation and replace the abnormal segment of aorta [4]. In poor surgical candidates where thoracic endografts are not a valid alternative for anatomical reasons (e.g. lack of landing zone) and a retrograde trans-femoral approach is problematic, direct percutaneous transaortic puncture remains a potential strategy for the interventionalist and the cardiac surgeon to access the neck of the APA. Although this approach does carry intrinsic procedural risks, it may potentially be safer and provide a less invasive strategy than open surgical intervention. To our knowledge, this is the first report of successful direct transcutaneous/transaortic approach for APA closure performed with the aid of triple fusion imaging. RESULTS Triple fusion multimodality imaging with merging of CTA and realtime TOE with fluoroscopy (HeartNavigator and EchoNavigator, Philips, Best Netherlands) allowed for both procedural planning and guidance, determining the optimal approach and the ideal point of chest wall entry, and guiding the deployment of devices. Amplatzer device sizing and positioning were equally essential for procedural efficacy and safety. Intraprocedural TOE and fluoroangiography showed total exclusion of the APA. The patient tolerated the procedure well and was safely extubated within 6 h. No peri (...truncated)