Abstract
Ascending Aortic pseudoaneurysms (AAP) are often formed as a result of prior thoracic surgery. In patients with large AAP, surgical correction is the established therapy. However, a group of patients are not suitable surgical candidates because of advanced age or multiple comorbidities. Instead, endovascular approach represents a viable option in this population. Here, we review the literature of the surgical and trans-catheter therapy for AAP. Additionally, we complement the review with a case presentation of a prohibitive surgical risk case that was treated with endovascular options including an unsuccessful septal occluder deployment, but final excellent angiographic AAP exclusion with coil embolization.
Highlights
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Ascending aortic pseudoaneurysms are prevalent in patients with prior thoracic surgery and surgical repair is the standard of care.
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In patients with prohibitive surgical risk, endovascular therapy with vascular occluders or plugs, stents grafts or coil embolization – or a multimodality of devices – is safe and feasible.
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There are no studies comparing surgery versus endovascular therapy.
1
Introduction
Ascending aortic pseudoaneurysms (AAPs) are formed after aortic injury including surgical cannulation, inflammatory process, blunt trauma or infections. As such, the incidence of ascending aortic pseudoaneurysms (AAP) is uncertain. Higher AAP incidence rates – as much as 60% – are present in patients with history of aortic surgery, whereas as low as 0.5% is present in the general population . AAP is commonly found as an incidental finding in an imaging study of the chest and, depending of the AAP size, it can produce compression symptoms such as shortness of breath, chest pain or present as a visible pulsating mass. Contrast-computer tomography angiography (CTA) of the chest represents the imaging study of choice for surveillance and to assist in deciding the timing of repair . CT scan imaging features of post-aortic surgery patients include low-attenuation perigraft material, active contrast material extravasation or perigraft gas collections surrounding the pseudoaneurysm which can be interpreted as a deshicence or infections of the graft . Given that most affected AAP patients have prior thoracic surgery, the treatment of AAP remains challenging. Although surgical repair has the largest patient registry data, trans-catheter AAP exclusion has emerged as an option in prohibitive risk surgical population. Here, we present a high-risk surgical patient treated endovascularly and review the various approaches to treat AAP.
2
Case presentation
A 61-year-old female was admitted with chest pain syndrome. Her history included a remote bioprosthetic mitral valve and ascending aorta (AA) repair in the context of endocarditis and type A aortic dissection, respectively. Her outside operative reports were missing because the hospitals were closed years ago. Cardiac biomarkers as well as coronary angiography were unrevealing. Contrast CTA of the chest showed AAP (6 × 4 cm, Fig. 1 and Video 1 ). The neck of the AAP was estimated at 7 mm near the right coronary ostium. Importantly, there were neither signs of systemic inflammatory response on the patient’s clinical presentation, nor features of infection such as perigraft abscess or dehiscence seen in the CT scan. As the heart team deemed the patient as high-surgical risk, the case seemed suitable for percutaneous closure with an endovascular occluder. A 6 French pigtail was positioned at the ascending aorta for angiography ( Fig. 2 ). An internal mammary (IM) diagnostic catheter and 0.014″ guidewire engaged the AAP. The wire was exchanged for 0.035″ Amplatz super stiff, and an 8 French IM guide was then advanced over the wire, and subsequently exchanged for the 9 French Amplatzer delivery sheath. Unfortunately, the delivery sheath could not be advanced into the PAA due unfavorable angulation between the aorta and AAP. The procedure was then aborted. Three days after, repeat procedure was performed with a different strategy. A 6 French internal mammary guiding catheter and 0.014″ wire engaged the AAP. A 4 French angled glide catheter was then advanced into the guiding catheter over the wire. Subsequently, thirty-five Azur hydrogel coils of different sizes (20 mm × 50 cm and 6 mm × 20 cm, Terumo) were deployed into the AAP cavity. Ascending aortic angiography showed exclusion of the PAA ( Fig. 3 and Video 2 ). Importantly, three-month follow-up CTA of the chest confirmed exclusion of the PAA ( Fig. 4 ).
2
Case presentation
A 61-year-old female was admitted with chest pain syndrome. Her history included a remote bioprosthetic mitral valve and ascending aorta (AA) repair in the context of endocarditis and type A aortic dissection, respectively. Her outside operative reports were missing because the hospitals were closed years ago. Cardiac biomarkers as well as coronary angiography were unrevealing. Contrast CTA of the chest showed AAP (6 × 4 cm, Fig. 1 and Video 1 ). The neck of the AAP was estimated at 7 mm near the right coronary ostium. Importantly, there were neither signs of systemic inflammatory response on the patient’s clinical presentation, nor features of infection such as perigraft abscess or dehiscence seen in the CT scan. As the heart team deemed the patient as high-surgical risk, the case seemed suitable for percutaneous closure with an endovascular occluder. A 6 French pigtail was positioned at the ascending aorta for angiography ( Fig. 2 ). An internal mammary (IM) diagnostic catheter and 0.014″ guidewire engaged the AAP. The wire was exchanged for 0.035″ Amplatz super stiff, and an 8 French IM guide was then advanced over the wire, and subsequently exchanged for the 9 French Amplatzer delivery sheath. Unfortunately, the delivery sheath could not be advanced into the PAA due unfavorable angulation between the aorta and AAP. The procedure was then aborted. Three days after, repeat procedure was performed with a different strategy. A 6 French internal mammary guiding catheter and 0.014″ wire engaged the AAP. A 4 French angled glide catheter was then advanced into the guiding catheter over the wire. Subsequently, thirty-five Azur hydrogel coils of different sizes (20 mm × 50 cm and 6 mm × 20 cm, Terumo) were deployed into the AAP cavity. Ascending aortic angiography showed exclusion of the PAA ( Fig. 3 and Video 2 ). Importantly, three-month follow-up CTA of the chest confirmed exclusion of the PAA ( Fig. 4 ).
