Pseudoaneurysm diagnosis and management





Introduction


Cardiac pseudoaneurysms are an uncommon occurrence; however, they are associated with significant risk of complications. , A pseudoaneurysm is a contained rupture of the arterial vessel or myocardial wall. A single layer of pericardium or adhesions lines the sac, increasing the risk of rupture and cardiac mortality approaching 30% to 50%. This is in comparison to a true aneurysm, which is thinning of the wall and contains all three layers of the endocardium, myocardium, and epicardium. ,


Previously, surgical management of pseudoaneurysms was considered the gold standard; however, it is associated with significant mortality approaching 23%. , Recent growth of structural heart procedures has helped in identifying percutaneous solutions for the management of pseudoaneurysms in patients who otherwise have high surgical risk. This chapter will discuss the various techniques and approaches for the diagnosis and management of pseudoaneurysms.


Incidence, presentation, and natural history


There are no prospective studies evaluating the natural history of pseudoaneurysms because of the low incidence. Retrospective studies have suggested that many patients are asymptomatic, with diagnosis made as an incidental finding on imaging. Other presentations include heart failure, chest pain, syncope, arrhythmias, or thromboembolism ( Table 29.1 ). Recently, cases related to wire perforations/injury during structural heart procedures such as transcatheter aortic valve replacement (TAVR) and mitral valve replacements have also been reported.



TABLE 29.1 ■

Clinical Presentation of Pseudoaneurysm





















Acute complication of myocardial infarction
Post-structural heart procedures
Heart failure
Dyspnea
Chest pain
Arrhythmias
Syncope
Systemic embolism
Incidental diagnosis on imaging done for other purposes


The left ventricle (LV) is the most common location of pseudoaneurysms. The etiology of LV pseudoaneurysms is variable according to the location. Myocardial infarction (MI) is the most common etiology, usually leading to an inferior-posterolateral scar and subsequent pseudoaneurysm formation. Cardiovascular surgery is the second most common cause. Right ventricular pseudoaneurysm is frequently seen with congenital surgeries, and paravalvular pseudoaneurysm, including mitral-aortic intervalvular fibrosa, can result as a complication from valve surgery or endocarditis.


Other causes of LV pseudoaneurysms include trauma to the chest, endocardial electrophysiologic procedures, and structural heart procedures such as TAVR.


Aortic pseudoaneurysms may occur after aortic repairs, trauma, or endarteritis. Coronary artery pseudoaneurysms can be related to prior percutaneous coronary intervention (PCI), vasculitis, or spontaneous dissection.


Diagnosis


In the contemporary era, multimodality imaging is the key for diagnosis and procedural planning in pseudoaneurysms. Biplane left ventriculography was the test of choice for surgical planning in the past and still has an important role in the assessment of the defect during percutaneous closure. Transthoracic echocardiogram (TTE) is usually the initial test in most patients. Transesophageal echocardiogram, especially 3D modality, may be helpful in some cases to assess the size, depth, and surrounding cardiac structures. Computed tomography (CT) scan with full 3D reconstruction or cardiac magnetic resonance (CMR) imaging is almost always performed to carefully plan any intervention by studying the following ( Figs. 29.1 to 29.3 ):



  • ■

    Precise pseudoaneurysm location to determine the best access approach (e.g., retroaortic, transseptal, transapical)


  • ■

    Size and extent of pseudoaneurysm and its neck to determine closure device size and type


  • ■

    Risk of interaction of occluder device with surrounding structures (e.g., risk of valve impingement and risk of coronary occlusion or compression)




Fig. 29.1


Multimodality imaging for diagnosis and management of pseudoaneurysms.

(A) Left ventricular apical pseudoaneurysm (yellow arrow) diagnosed on transthoracic echocardiogram. (B) Computed tomography scan was used for procedural planning to assess the dimensions of the pseudoaneurysm. The procedure was performed successfully, as shown in Fig. 29.7 .



Fig. 29.2


Computed tomography (CT) scan for procedural planning.

(A) CT scan showing a paravalvular pseudoaneurysm close to the bioprosthetic mitral valve. (B) Different views are used for procedural planning. This was used to perform the procedure as shown in Fig. 29.9 .



Fig. 29.3


Computed tomography (CT) scan for preprocedural planning of left ventricular outflow tract (LVOT) pseudoaneurysm closure.

Coronal (A) and axial (B) views of cardiac computed tomography angiogram (CTA) showing large postsurgical subaortic pseudoaneurysm. The pseudoaneurysm dimensions were 26 mm by 18 mm with 7-mm neck (C). The pseudoaneurysm was in close proximity to the mechanical aortic valve, increasing the risk of valve impingement. The procedure was performed successfully as described in Fig. 29.6 with an occluder device that was 50% oversized to the pseudoaneurysm neck.

(Reproduced with permission from Al-Hijji MA, Guerrero M, Rihal CS, Eleid MF. Transapical percutaneous closure of rapidly expanding post-surgical left ventricular outflow tract pseudoaneurysm. Catheter Cardiovasc Interv. 2019;94(6):859-862.)


The field of 3D printing further enhanced preprocedural planning and management of pseudoaneurysms. Patient-specific 3D printed cardiac models with cardiac tissue characteristics have allowed for bench testing to simulate closure procedures and reduce the rate of trial and error ( Fig. 29.4 ).




Fig. 29.4


Bench testing on 3D printed patient-specific cardiac models.

Printed cardiac 3D soft model representing tissue characteristics was used to determine the best access site and guiding catheter to engage the subaortic pseudoaneurysm. Transapical (A) access allowed for the most coaxial and feasible approach compared with transseptal (B) access. A 6F left coronary bypass guiding catheter (A) provided the best coaxial engagement of the pseudoaneurysm, followed by a Judkins right 4 guide (C). Amplatz Left-1 guiding catheter did not provide a great fit, given the narrow left ventricular outflow tract.

(Reproduced with permission from Al-Hijji MA, Guerrero M, Rihal CS, Eleid MF. Transapical percutaneous closure of rapidly expanding post-surgical left ventricular outflow tract pseudoaneurysm. Catheter Cardiovasc Interv. 2019;94(6):859-862.)


Guidelines and patient selection


There are no specific guidelines for the treatment of pseudoaneurysms. Fig. 29.5 outlines our approach to management.




Fig. 29.5


Approach to the management of pseudoaneurysms.


The indications for treatment may include:



  • ■

    Symptoms


  • ■

    Acute complications of MI


  • ■

    Acute complication of a structural/electrophysiologic procedure


  • ■

    High risk of rupture (Laplace law: Wall stress = Pressure * radius / 2)


  • ■

    Presence of thrombus and risk of thromboembolism.



Conservative management


Minimal data are available on conservative management of pseudoaneurysms. In a systematic review of 31 patients who were managed conservatively, 48% died at a median of 1 week, with the remainder of patients alive at a median of 156 weeks. This suggests that if the patient survives the early period after pseudoaneurysm formation and their risk of surgical or percutaneous treatment is considered prohibitive, conservative management may be appropriate. However, this should be pursued with caution, and very close follow-up with serial imaging is important. We previously published a case of conservatively managed LV pseudoaneurysm after endocardial ablation in a congenital heart disease patient with a single ventricle. The patient was considered at prohibitive risk for repeat surgery and percutaneous closure carried a high risk of interfering with the single mechanical valve. The patient was followed serially with CT scans for 3 months (available follow-up until 1 year) without any change in the size of pseudoaneurysm. She was already on anticoagulation for the mechanical valve.


In patients who are managed conservatively, anticoagulation is recommended to reduce the risk of thrombus formation and systemic embolism.


Percutaneous closure of pseudoaneurysms


Ventricular and aortic pseudoaneurysms


Percutaneous approaches have allowed for a less invasive treatment of pseudoaneurysms. The access to pseudoaneurysms depends on its location. The retroaortic (femoral artery) approach is usually utilized for apical, posterolateral, and aortic pseudoaneurysms. The antegrade (transseptal) approach can be used in posterobasal pseudoaneurysms or in patients with a mechanical aortic valve. A transapical approach may be required in patients with double (aortic and mitral) mechanical valves or if the pseudoaneurysm is not reachable, such as in cases of a left ventricular outflow tract (LVOT) pseudoaneurysm ( Fig. 29.6 ). TTE is used to identify the true apex, and the transapical puncture site is marked using a sterile marker. Using fluoroscopic imaging, the transapical puncture is performed with 16-cm gauge × 10-cm Angiocath needle and a 6F sheath is introduced. Catheters are introduced through this sheath, and the occluder device and/or endovascular coils are deployed. The transapical access is closed using 4- to 6-mm AVP II plug after removal of the sheath.




Fig. 29.6


Direct transapical access for left ventricular outflow tract (LVOT) pseudoaneurysm closure.

(A) Fluoroscopic image of transapical access guided by pressure tracings. (B) Successful placement of left coronary bypass (LCB) guide catheter in the subaortic pseudoaneurysm (yellow arrow). (C) Subaortic pseudoaneurysm was successfully sealed using a 10-mm AVP II device (yellow arrow) with contrast injection showing reduced flow to the pseudoaneurysm. (D) The transapical access site was successfully closed with a 4-mm AVP II device (yellow arrow).

(Reproduced with permission from Al-Hijji MA, Guerrero M, Rihal CS, Eleid MF. Transapical percutaneous closure of rapidly expanding post-surgical left ventricular outflow tract pseudoaneurysm. Catheter Cardiovasc Interv. 2019;94(6):859-862.)


The following techniques can be used to approach percutaneous closure of pseudoaneurysms ( Figs. 29.11 to 29.19 describe the procedural steps for percutaneous closure using various methods.):



  • ■

    Occluder devices


  • ■

    Coil embolization


  • ■

    Combination of occluder device and coil embolization




Fig. 29.11


For a retrograde approach, a 6F to 8F sheath is inserted in the femoral artery using ultrasound guidance.

After the aortogram, we engage the pseudoaneurysm. We typically start with a 6F multipurpose guide catheter with a telescoping 5F 125-cm multipurpose diagnostic catheter and a stiff-angled Glidewire to engage the pseudoaneurysm. Different guiding catheters may have to be utilized depending on the location of the pseudoaneurysm.

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Jan 3, 2021 | Posted by in CARDIOLOGY | Comments Off on Pseudoaneurysm diagnosis and management

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