Abstract
We describe the first case of an endovascular repair for a pseudoaneurysm of the ascending aorta using the Valiant Navion EVO® low-profile thoracic endograft from Medtronic™. A successful outcome from a potentially fatal condition in a severely compromised patient was achieved.
Highlights
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Pseudoaneurysm of the ascending aorta is potentially fatal and has a high mortality rate if left untreated.
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Vascular plugs and occluder devices are described for endovascular repair of pseudoaneurysms of the ascending aorta.
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This report demonstrates the first successful endovascular exclusion of the pseudoaneurysm using an investigational device.
1
Introduction
Pseudoaneurysm of the ascending aorta is a potentially fatal condition with estimated mortality up to 61% if left untreated [ ]. Mortality rates associated with surgical treatment range from 29 to 46% [ , ]. There have been previous isolated case reports and reviews of the literature detailing endovascular management for this condition. Most reports have demonstrated success at least in the short-term with placement of vascular plugs and occluders to exclude the pseudoaneurysm and induce thrombosis.
2
Case report
A middle-aged female patient presented in extremis with intra-pericardial rupture of a Type A Aortic Dissection. She previously had undergone total arch replacement with re-suspension of the aortic valve. In the initial procedure a 30 mm Dacron® graft was placed as an interposition graft with the innominate and left common carotid arteries re-implanted as an island graft onto the interposition graft. The innominate and left common carotid arteries had a common origin from the aorta, the so called ‘bovine’ variant. A graft-to-graft anastomoses with a second 30 mm Dacron® interposition graft with a 10 mm side arm to the left subclavian artery was used for total replacement of the aortic arch. Owing to severe swelling, her chest was left open and subsequently closed without event.
The patient did well, only to present six months later with a pulsatile mass in the mid-sternal region. Computed Tomography Angiogram (CTA) revealed a large pseudoaneurysm arising from the Dacron® interposition graft in the mid-ascending aorta ( Fig. 1 ). An infectious disease work-up for the etiology of the pseudoaneurysm was negative and suture line breakdown was felt to be the most likely cause. The patient’s physicians felt she was a prohibitive risk for an open surgical repair of this pseudoaneurysm. She was at imminent risk of death from rupture of the pseudoaneurysm. In addition to the general operative risks, the external iliac access vessels measured approximately 6 mm in diameter, making her ineligible for endovascular repair of the pseudoaneurysm using conventional endografts. We requested Medtronic™ to release the Valiant Navion Evo® device for compassionate use to save the life of this patient. The delivery system of the Valiant Navion Evo® 37 mm endograft that would be required to treat the patient measures 20 Fr as opposed to 24 Fr for the standard device. The Valiant Evo Thoracic Endograft® is currently an investigational device. Our institution is an approved clinical trial site for the device [NCT02652949] and the physicians have been appropriately trained and certified in the implantation of the device. Full disclosure regarding the investigational nature of the device and the inherent risks of the procedure and all treatment alternatives were carefully discussed with the patient and consent was obtained to proceed with the repair. Comprehensive surgical planning was prepared by the patient’s care team from thin slice 3-D reconstruction of the CTA of the chest ( Fig. 2 ).
A left subclavian to left common carotid artery bypass using an 8 mm heparin bonded and externally supported Propaten® graft (WL Gore and Associates™) was first performed as the intention was to cover the origin of the innominate and left common carotid arteries. The arteries had a common origin and had been re-implanted as an island onto the Dacron® interposition graft for replacement of the ascending aorta. Perfusion to the cerebral vessels would be provided by virtue of the bypass graft with direct perfusion from the left subclavian to the left common carotid artery and in a retrograde manner to the innominate and right common carotid artery. This coverage of the great vessels of the arch, except for the left subclavian artery, was necessary to gain a sufficient seal zone distally to provide a durable endovascular repair of the pseudoaneurysm.
Access was obtained from the bilateral common femoral arteries which were pre-closed with two 6 French Pro-Glide® sutures (Abbott Medical™) on the right and a single suture on the left. Additionally, the common femoral vein was accessed for rapid ventricular pacing. With rapid ventricular pacing at 180 beats per minute and appropriate hypotension the Valiant Navion Evo® 37 × 37 × 90 mm device was deployed directly above the sino-tubular junction with the nose cone of the delivery device embedded deep in the left ventricle and supported by a rigid double curved Lunderquist® wire ( Fig. 3 ). The device lay at an angle resulting in an endoleak with the pseudoaneurysm still pressurized. Next, a second Valiant Navion Evo® device 37 × 37 × 44 mm was placed in an overlapping fashion with the first device extending more distally into the arch, once again under rapid ventricular pacing. The second device corrected the angulation of the first and obtained a perfect seal of the pseudoaneurysm ( Fig. 3 ). She has subsequently been seen in follow-up approximately six months since the repair and continues to do well with complete exclusion of the pseudoaneurysm documented by follow-up CTA ( Fig. 1 ).
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