Abstract
Aortic pseudoaneurysms (PSAs) are common complications following cardiac surgery, and carry significant morbidity and mortality. Surgical management of aortic PSAs is associated with high mortality, however there are emerging reports of transcatheter techniques for closure of aortic PSAs. We present two cases of ascending aorta PSA which developed following cardiac surgery and were treated percutaneously with novel closure devices. We also describe a comprehensive review of the literature of all published cases of ascending aorta PSA which have been closed percutaneously, and report on the success rate and available devices for percutaneous closure.
1
Introduction
Aortic pseudoaneurysms (PSAs) have been reported to develop following thoracic surgeries, including aortic valve replacement, coronary artery bypass grafting (CABG), aortic dissection repair, and orthotopic cardiac transplantation . Other common potential etiologies include endocarditis and trauma . Clinical presentation is variable, with some experiencing symptoms from mass effect on surrounding structures, while others remain asymptomatic for months to years . The incidence of aortic PSAs following aortic or cardiac surgery is 23% at 15 years following surgery . Morbidity associated with PSAs relates to the potential for aortic rupture, thrombosis, distal embolization, and fistula formation . Mortality rates up to 61% have been reported if aortic PSAs remain untreated . Options for repair include surgery, endovascular graft placement, thrombin injection, coil embolization and more recently, percutaneous device closure . Mortality rates associated with surgical management range from 29% to 46%, further complicated by the technical difficulties of surgery in patients who have undergone prior complex thoracic surgeries . These features have made percutaneous closure an attractive option for high-risk surgical patients. However, since the location, etiology, and size of every aortic PSA are different, it is difficult to find a “one size fits all” approach to closure.
We present two cases of percutaneous closure of ascending aortic PSA with two different types of transcatheter deployed devices.
2
Case report
2.1
Case 1
A 59 year old male with a past medical history including ascending aortic dissection status post repair 12 years ago, coronary artery disease status post CABG, HIV (on HAART therapy), and hypertension presented with dyspnea. Transthoracic echocardiogram (TTE) demonstrated an ejection fraction of 37% and moderate aortic regurgitation with an ascending aortic aneurysm measuring 7 cm. Cardiac MRI demonstrated an enlarged aortic root with an aortic PSA (neck measuring 14 mm in transverse dimension) arising distal to the interposition graft anastomosis ( Fig. 1 ). Given concomitant comorbidities, he was deemed to have a prohibitively high surgical risk and was referred for percutaneous transcatheter treatment.
