A Magic Port-A-Cath

Ming-Chih Lin, MD, PhD

Te-Kau Chang, MD

Yun-Ching Fu, MD, PhD

Sheng-Ling Jan, MD

A 7-year-old boy with Burkitt lymphoma was referred by pediatric oncologists for severe chest pain when flushing a Port-a-cath catheter. Chest x-ray showed a dislodged Port-a-cath catheter and cardiomegaly ( Fig. 7.1 A) compared with the last film taken 6 months earlier ( Fig. 7.1 B). Echocardiography revealed pericardial effusion and a dislodged catheter in the pericardium.

The Patient’s Chest X-Ray Findings.

(A) Chest x-ray on presentation revealed a dislodged Port-a-cath catheter and cardiomegaly (black arrow ). (B) Previous chest x-ray taken 6 months before showed the Port-a-cath catheter positioned at the superior vena cava (Online Video 7.1 ).

To avoid surgical removal, access was established using a 7F sheath via the subxiphoid approach into the pericardium ( Fig. 7.2 A). A 5F end-hole catheter was then introduced through the sheath, and a 25-mm AndraSnare catheter (Andramed, Reutlingen, Germany) was used to capture the dislodged Port-a-cath catheter ( Fig. 7.2 B), which was then retrieved through the sheath ( Fig. 7.2 C)

Interventional Procedure.

(A) A 7F short sheath was introduced into the pericardium via the subxiphoid approach. (B) A 25-mm snare catheter was used to capture the catheter. (C) The dislodged catheter was pulled out of the pericardium through the sheath along with the snare catheter. (D) The 7F sheath was changed to a pigtail drainage tube.

After the procedure, the 7F sheath was changed to a 6F pigtail drainage catheter ( Fig. 7.2 D), and a total of 170 mL of bloody fluid was drained. The procedure took about 14 min, and fluoroscopy time was 1.6 min. The drainage tube was removed 3 days later after confirming there was no more hemopericardium by echocardiography (OnlineVideo 7.1 ).

Port-a-cath catheter dislodgment is not an unusual complication. The reported incidence rate ranges from 1.4% to 4.1%. Transcatheter retrieval was introduced in 1967, and after the invention of the Amplatz Goose Neck snare catheter (ev3 Endovascular, Plymouth, Minnesota), the procedure has since become very effective, with almost a 100% success rate. However, transcutaneous retrieval of a Port-a-cath catheter from the pericardium has not been previously reported. The possible mechanism is the vigorous flushing of the thrombosed catheter, causing it to disconnect and penetrate the thin wall of the right atrium like an arrow. The negative pressure of the thorax then caused the entire catheter to migrate into the pericardium. This case emphasizes that flushing of a Port-a-cath catheter should be gently done, and percutaneous retrieval may be a safe and effective method.

A New Tool to Manage Side-Branch Occlusion After Covered-Stent Implantation for Vascular Complications: The Neocarina Reconstruction Technique

Chiara Bernelli, MD

Francesco Maisano, MD

Alaide Chieffo, MD

Matteo Montorfano, MD

Jaclyn Chan, MBBS

Davide Maccagni, RT

Antonio Colombo, MD

Endovascular stent-graft implantation can be used to manage access site vascular complications during transcatheter aortic valve implantation. Nonetheless, the deployment of these devices may be technically challenging.

An 85-year-old man underwent a transfemoral transcatheter aortic valve implantation using a 29-mm CoreValve ReValving system (Medtronic Inc., Minneapolis, Minnesota). After failure of therapeutic access preclosure by Prostar XL (Abbott Vascular Devices, Redwood City, California), a Viabahn endoprosthesis (W.L. Gore & Associates, Flagstaff, Arizona) was deployed. However, because the previous contralateral wire was inadvertently positioned in the profunda, the Viabahn occluded the superficial femoral artery ( Fig. 7.3 A). Therefore, to reaccess the superficial femoral artery, a Brockenbrough needle and Mullins sheath (Medtronic, Minneapolis, Minnesota) were used to perforate the covered stent ( Fig. 7.3 B–C). After puncture, a 0.014-inch wire was advanced in the superficial femoral artery and dilation of the covered stent with a 5.5- × 20-mm balloon was performed ( Fig. 7.3 D). Branch patency was restored with thrombolysis in myocardial infarction flow grade 3 and a “neofemoral carina” was created ( Fig. 7.3 E).

The Neocarina Reconstruction Technique.

(A) Femoral contrast angiography via the crossover sheath demonstrating superficial femoral artery (SFA) occlusion after Viabahn implantation. Schematic (B) and angiographic (C) representation of the Brockenbrough needle and Mullins sheath used to pass through Viabahn endoprosthesis. (D) Dilation with 5.5- × 20-mm balloon through the endoprosthesis. (E) Restoration of SFA patency with thrombolysis in myocardial infarction flow grade 3.

This “neocarina reconstruction” technique may be applied to manage vascular complications in various interventional procedures. However, the clinical impact of this new technique on the long-term patency of the stent graft and the need for close surveillance remain unclear.

Ascending Aorta to Main Pulmonary Artery Fistula After Orthotopic Heart Transplantation: Successful Percutaneous Closure Employing an Amplatzer Duct Occluder

Todd L. Kiefer, MD

John P. Vavalle, MD

Adam Devore, MD

Chetan B. Patel, MD

Joseph Rogers, MD

Carmelo Milano, MD

Thomas R. Gehrig, MD

J. Kevin Harrison, MD

A 60-year-old man with end-stage heart failure underwent orthotopic heart transplantation. Before transplantation, he had elevated pulmonary artery (PA) pressures (60/17 mm Hg; mean PA, 35 mm Hg) and pulmonary vascular resistance (PVR) (6.6 Wood units). After transplantation, he initially did well, with normalization of PA pressures (27/13 mm Hg; mean PA, 20 mm Hg). Several months later, however, he developed overt right-sided heart failure. Invasive hemodynamic evaluation demonstrated severe pulmonary hypertension (92/51 mm Hg; mean PA, 66 mm Hg) with a PVR of 10 Wood units. There was no evidence of allograft rejection or pulmonary embolism. Transthoracic echocardiogram demonstrated right ventricular (RV) systolic dysfunction and enlargement. Color flow Doppler imaging demonstrated continuous flow from the ascending aorta into the main PA. The anatomy was confirmed by computed tomographic angiographic imaging ( Fig. 7.4 ).

Computed Tomographic Angiography (CTA) Imaging of the Aorta-to-Pulmonary Artery Fistula.

(A) Axial oblique CTA image demonstrating contrast flow from the ascending aorta ( Ao ) into the distal main pulmonary artery ( PA ). (B) Coronal CTA image demonstrating contrast flow from the ascending Ao into the PA at a site of out-pouching along the inner curvature of the Ao ( arrowhead ). A , anterior; F , feet; H , head; L , left; MIP , maximum-intensity projection; P , posterior; R , right.

Oximetry measured a modest left-to-right shunt at the PA level and no right-to-left shunt (Qp/Qs shunt fraction = 1.2:1). Percutaneous closure of the aorta-to-PA fistula was recommended.

A 6F Judkins Left 3.5 (Cordis Inc., Miami, Florida) guide catheter inserted via the right femoral artery engaged the fistula origin in the ascending aorta. Biplane angiography demonstrated the fistulous connection ( Fig. 7.5 and Online Video 7.2 , and Fig. 7.6 and Online Video 7.3 ).

Still Cineangiographic Image in the Straight Anterior-Posterior Projection.

Note the flow from the ascending aorta ( Ao ) to the pulmonary artery ( PA ) (Online Video 7.2 ).

Still Cineangiographic Image in the 16° Left Anterior Oblique Projection.

Note the Judkins Left 3.5 guide catheter entering the fistula from the ascending aorta ( Ao ) and contrast opacifying the pulmonary artery ( PA ) (Online Video 7.3 ).

A 0.035-inch Glidewire (Terumo Medical Corporation, Somerset, New Jersey) was advanced via the guide catheter through the fistulous connection into the PA and externalized out the right femoral vein using a 25-mm loop snare (ev3 Endovascular, Plymouth, Minnesota).

Based on computed tomographic and angiographic measurements (a sizing balloon would not cross the fistula), a 12/10 mm Amplatzer Duct Occluder was selected and deployed via a TorqVue delivery sheath (St. Jude Medical, St. Paul, Minnesota) ( Fig. 7.7 ). Aortography confirmed stable and ideal positioning of the device within the fistula, with dramatic reduction of flow into the PA ( Fig. 7.8 , Online Video 7.4 ). The patient did well postprocedure without complications. At follow-up evaluation 4 months after the procedure, the patient reported improvement in his dyspnea, increased energy, and diminished peripheral edema. In addition, transthoracic echocardiogram demonstrated decreased RV size and Doppler-derived RV systolic pressure with no residual shunt.

Still Cineangiographic Image of the Ascending Aorta Viewed from 32° Right Anterior Oblique.

Note the course of the 9F, 45° TorqVue delivery sheath ( arrow ) from the pulmonary artery ( PA ) into the aorta ( Ao ).

Still Cineangiographic Image of the Ascending Aorta (18° Right Anterior Oblique).

Note the stable position of the deployed 12/10 mm Amplatzer Duct Occluder device ( arrow ) and the absence of contrast flow from the aorta ( Ao ) into the pulmonary artery ( PA ) (Online Video 7.4 ).

Review of the literature failed to reveal a report of the posttransplantation complication described in our patient: formation of a fistula between the aorta and PA after heart transplantation. The approach described for percutaneous closure represents a novel and less morbid solution compared with further open cardiac surgery.

Embolotherapy in Giant Pulmonary Arteriovenous Malformations: Blocking the Exit—Reducing the Risk of Periinterventional Stroke?

Christoph M. Happel, MD, PhD

Kamal Nashwan, MD

Harald Bertram, MD

Several publications report strokes early after embolotherapy for pulmonary arteriovenous malformations (pAVM). Various mechanisms are discussed for this event, including embolization of newly formed thrombotic material originating from the aneurysmal sac after occlusion of the arterial feeder.

To reduce the risk of periinterventional stroke in a 22-year-old woman with a giant pAVM (66 × 47 × 70 mm ³ ) ( Fig. 7.9 A–B, Online Video 7.5 ), after occlusion of the main feeding artery (16-mm vascular plug II), we additionally blocked the draining vein via a transseptally advanced 18-mm vascular plug II (both devices: AGA Medical Corporation, Plymouth, Minnesota) ( Fig. 7.9 C, Online Video 7.6 ). The patient recovered uneventfully; pulse oximetry rose from approximately 85% before intervention to 98%. Four months after embolotherapy, a computed tomography scan confirmed the excellent result ( Fig. 7.9 D). A minor residual pAVM was not targeted, because the patient refused a second procedure. Two years after embolotherapy, the patient is in good clinical condition with no neurologic sequelae.

Pulmonary Arteriovenous Malformation (pAVM) Before and After Intervention.

(A) Angiography demonstrating the giant pAVM and an additional pAVM (Online Video 7.5 ). (B) Three-dimensional computed tomography (3D-CT) reconstruction before intervention. (C) Angiography after placement of both vascular plugs (Online Video 7.6 ). (D) 3D-CT reconstruction 4 months after occlusion showing complete occlusion of the giant pAVM, a residual smaller pAVM, and normal-sized pulmonary vessels. Arrow , feeding artery; arrowhead , draining vein; large asterisk , giant pAVM; small asterisks , additional pAVMs; arrowhead 1 , arterial vascular plug; arrowhead 2 , venous vascular plug.

Endovascular Repair of Ruptured Pseudoaneurysm of Left Internal Mammary Graft After Redo Aortic Valve Replacement and Coronary Artery Bypass Grafting

Sanjeev U. Nair, MBBS, MD

Nainesh C. Patel, MD

David A. Cox, MD

Pseudoaneurysm of internal mammary arteries may be asymptomatic or present within weeks after a sternotomy procedure with features such as chest swelling, atypical chest pain, and angina or rarely with rupture and exsanguination.

A 62-year-old man who had undergone coronary artery bypass grafting and aortic mechanical valve replacement presented a decade later with angina and dyspnea. He was found to have a partially thrombosed aortic prosthetic valve. The patient underwent a reoperation with aortic bioprosthetic valve replacement. Two weeks later the patient was readmitted with acute chest pain and ST-T changes on the electrocardiogram. Urgent coronary angiography showed the previously placed coronary artery grafts to be patent. However, there was a large (1 × 1 cm) pseudoaneurysm of the left internal mammary artery (LIMA) graft with leakage of contrast into the mediastinum at the site of the pseudoaneurysm, suggesting an associated rupture ( Fig. 7.10 , Online Video 7.7 ). Utilizing the femoral arterial approach, a 7F LIMA guide was used to wire the LIMA, and a 3.0- × 26-mm covered Jostent stent graft (Jomed International AB, Helsingborg, Sweden) was placed and inflated to 19 atm. This completely sealed the ruptured pseudoaneurysm, and postdilation was done with a 3.0 Quantum balloon to 20 atm ( Fig. 7.11 , Online Video 7.8 ). An excellent result was obtained, with thrombolysis in myocardial infarction flow grade 3 distally. There was good flow down to the left anterior descending coronary artery (LAD) with some evidence of wire spasm, which improved with intracoronary nitroglycerine. The LAD diagonal, as well as the collaterals to the right coronary artery, were patent. Multiple angiographic views were taken that showed no evidence of further extravasation of contrast ( Fig. 7.12 , Online Video 7.9 ). The patient was eventually discharged home on dual-antiplatelet therapy (aspirin and clopidogrel).

Right Anterior Oblique and Left Anterior Oblique Views, Respectively, by Coronary Angiography.

These views demonstrate a large (1 × 1 cm) pseudoaneurysm in the midsection of the left internal mammary artery graft with associated rupture as suggested by contrast leakage into the mediastinum (Online Video 7.7 ). The left panel shows the right anterior oblique view, and the right panel shows the left anterior oblique view.

Covered Stent (Jostent) Placement at the Site of the Ruptured Pseudoaneurysm in the Left Internal Mammary Artery (LIMA) Graft.

By the femoral arterial route, a 7F LIMA guide was used to wire the LIMA. A 3.0- × 26-mm covered Jostent stent (Jomed International AB, Helsingborg, Sweden) was placed at the site of the rupture and inflated to 19 atm pressure (Online Video 7.8 ).

Poststent Left Internal Mammary Artery (LIMA) Graft With Good Distal Thrombolysis In Myocardial Infarction (TIMI) Flow.

TIMI flow grade 3 was obtained distally after placement of covered stent (Jostent) at the site of the ruptured LIMA graft pseudoaneurysm (Online Video 7.9 ). The associated rupture is completely sealed off as evidenced by lack of contrast extravasation.

Thus, a ruptured pseudoaneurysm of an internal mammary graft can be successfully and safely repaired percutaneously using a covered stent; this avoids the risks and complications associated with sternotomy.

Endovascular Stenting of Suture Line Supravalvular Pulmonic Stenosis After Orthotopic Heart Transplantation Using Rapid Pacing Stabilization

Justin Z. Lee, MD

Kwan S. Lee, MD

Aiden Abidov, MD

Ricardo A. Samson, MD

Kapildeo Lotun, MD

A 61-year-old woman, 6 months after orthotopic heart transplantation (OHT), presented with gradual-onset class III dyspnea and fatigue for 4 months. Her transplantation procedure was significant for right ventricular sternal adhesions after left ventricular assist device placement and significant size mismatch between the donor and recipient aortas, requiring fashioning of the donor aorta to correct the mismatch. A computed tomography angiogram ( Fig. 7.13 ) showed an eccentric anastomotic line supravalvular stenosis 1.5 cm distal to the pulmonic valve, 1.4 × 2.0 cm at the narrowest portion with poststenotic dilation of 4.0 cm. Right ventricular systolic pressure (RVSP) was 60 mm Hg + central venous pressure with supravalvular flow acceleration.

Computed Tomography Angiogram Showing Pulmonary and Aortic Anastomosis Stenotic Lesions After Orthotopic Heart Transplantation.

Computed tomography angiogram showing great vessel anastomotic lesions after orthotopic heart transplantation. (A) Focal proximal aortic stenosis ( yellow arrow ) that was hemodynamically insignificant. (B) Proximal main pulmonary artery stenosis ( red arrow ) with poststenotic dilation ( green arrow ). The stenosis was hemodynamically significant, with a gradient across the lesion of 22 mm Hg, and a right ventricular systolic pressure of 60 mm Hg + central venous pressure.

The proximity of the stenosis to the pulmonary valve led to an unsuccessful initial angioplasty attempt because there was persistent distal migration of the balloon during inflation and an inability to maintain a stable balloon position. The procedure was reattempted with angioplasty and stenting using a Palmaz 39 10-mm balloon-expandable stent (Cordis, Miami, Florida) mounted on a balloon-in-balloon 20- × 40-mm balloon (NuMED, Hopkinton, New York) using a rapid pacing stabilization technique with transesophageal echocardiographic guidance ( Figs. 7.14 , 7.15 ). Postdilation was then performed with a Tyshak II 25- × 40-mm balloon (B. Braun, Bethlehem, Pennsylvania) ( Fig. 7.16 ). The procedure was successful with reduction of the peak gradient from 22 mm Hg to 3 mm Hg and resulting peak RVSP reduction from 70 mm Hg to 51 mm Hg with minimal pulmonary artery diameter increase from 1.4 cm to 2.2 cm. The patient’s fatigue and dyspnea resolved.

Intraprocedural Transesophageal Echocardiographic Images of Pulmonary Stenosis Intervention.

(A) Preprocedural modified mid upper esophageal transesophageal echocardiographic view of the great vessels showing supravalvular pulmonic stenosis in the area of surgical anastomosis after orthotopic heart transplantation ( red arrow ), 15 mm distal to the pulmonary valve ( blue arrow ). Poststenotic dilation of main pulmonary artery ( green arrow ) is also seen in this view. (B) Tyshak II balloon deployment ( purple arrows ). (C) Final stent position ( black arrows ) above pulmonary valve ( blue arrow ).

Translesional Stenosis Gradients by Doppler Assessment Before and After Procedure.

Images show continuous-wave (CW) Doppler findings across the main pulmonary artery lesion before the intervention (A) and immediately after the balloon valvuloplasty and stent implantation (B). CW recordings document a decrease in pressure gradient across the lesion from 22 to 3 mm Hg. There was evidence of mild pulmonary regurgitation before the procedure with no worsening after the procedure.

Right-Sided Heart Angiography Before and After Stent Deployment.

(A) Initial right ventriculogram showing normal pulmonary valve annulus ( blue arrow, A : 24.9 mm) and supravalvular pulmonic stenosis ( red arrow, B : 10.9 mm). (B) Postdilation of a Palmaz 39- × 10-mm stent with a Tyshak II 25- × 40-mm balloon during rapid ventricular pacing. (C) Poststent right ventriculogram.

This is the first described case of suture line supravalvular pulmonic stenosis post-OHT and highlights the possibility of successful endovascular therapy using rapid pacing as a stabilization technique for device deployment. Intraprocedural transesophageal echocardiographic imaging was instrumental in positioning the stent secondary to the proximity of the pulmonary valve.

Extravasation From an Accessory Renal Artery: A Critical Complication Associated With Percutaneous Coronary Intervention

Nobuaki Kobayashi, MD

Noritake Hata, MD

Tomoyuki Kuwako, MD

Wataru Shimizu, MD

A 72-year-old woman was admitted with acute anterior ST-segment elevation myocardial infarction and underwent emergency primary percutaneous coronary intervention (PCI) at the mid portion of the left anterior descending coronary artery. After the procedure, she suffered from shock and severe abdominal pain. Enhanced computed tomography showed marked perirenal hematoma ( Fig. 7.17 ). An aortogram revealed that the left kidney was supplied by double renal arteries and that an accessory renal artery originated from the L3-L4 intervertebral disk level and traveled in parallel with the aorta ( Fig. 7.18 A, Online Video 7.10 ). Furthermore, a selective injection demonstrated that the extravasation occurred from the left accessory renal artery ( Fig. 7.18 B–C, Online Video 7.11 ). Transcatheter embolization with Gelfoam (Pfizer, Tokyo, Japan) was performed, and final angiograms showed complete embolization of the left accessory renal artery in the absence of extravasation ( Fig. 7.19 A–C, Online Videos 7.12 and7.13 ).

Enhanced Abdominal Computed Tomography.

Computed tomography showed marked left perirenal hematoma ( asterisks ).

Initial Angiograms of Abdominal Arteries.

(A) An abdominal aortogram. The left kidney is supplied with double renal arteries. White arrows show the left accessory renal artery originating from the L3-L4 intervertebral disk level and traveling in parallel with the aorta (Online Video 7.10 ). Early- (B) and late- (C) phase selective left accessory renal arteriograms (Online Video 7.11 ). White arrowheads show extravasation from the left accessory renal artery.

Posttranscatheter Embolization Angiograms for Abdominal Arteries.

An abdominal aortogram (A) (Online Video 7.12 ) and early- (B) and late- (C) phase selective left accessory renal arteriograms (Online Video 7.13 ). Yellow arrows show the complete embolization of the accessory renal artery. Extravasation is not observed ( yellow arrowheads ).

In the present case, it was suspected that the extravasation was caused during the primary PCI when a 0.035-inch guidewire was used to advance a guiding catheter. Guidewire penetration into the left accessory renal artery went undetected because the accessory renal artery originated from a lower level and traveled in parallel with the aorta. Renal artery variations are common; in a previous report, the frequency of a left accessory renal artery was found to be 13%. However, the frequency of left accessory renal arteries originating from regions lower than lumbar spine L3 has been reported to be only 6% of all left accessory renal arteries.

Iatrogenic Aortocoronary Arteriovenous Fistula: Percutaneous Management of a Surgical Complication

Zaher Fanari, MD

Jhapat Thapa, MD

Armin Barekatain, MD, MSC

Kevin Copeland, DO

James T. Hopkins, MD

Iatrogenic aortocoronary arteriovenous fistula (ACAVF) resulting from placement of an arterial graft to a cardiac vein is a rare complication of coronary artery bypass grafting (CABG). ^, Most patients present postoperatively with angina as a result of residual ischemia that is due to either an unbypassed artery or a coronary steal syndrome (CSS). A 74-year-old woman presented with recurrence of angina with a history of multivessel coronary artery disease after CABG in 2006 with a left internal mammary artery (LIMA) Y graft to the left anterior descending and first diagonal coronary arteries, and sequential saphenous vein graft (SVG) to the circumflex obtuse marginal and the posterior descending arteries, and recurrent angina secondary to an occluded SVG resulting in a second CABG with a free radial graft anastomosed to the LIMA and then placed sequentially to the obtuse marginal and posterior descending arteries. Coronary angiography showed that the radial graft was in reality anastomosed to the left circumflex vein ( Fig. 7.20 A–B). This iatrogenic fistula resulted in a dilated tortuous LIMA and radial grafts with possible CSS that explained the ischemia. Given that the patient was not a candidate for a third surgery and that medical therapy was not controlling the patient’s angina, a decision for percutaneous closure was made. An initial attempt with coil embolization of the coronary vein was unsuccessful because the interlock coils did not deploy appropriately. A deployment of a 3-mm Amplatzer vascular plug II (St. Jude Medical, Saint Paul, Minnesota) was successful, with no residual flow into the coronary sinus from the radial graft ( Fig. 7.20 C–F). In summary, ACAVF is a rare but serious complication of CABG that may result in ischemia secondary to CSS or high-output heart failure when a significant degree of left-to-right shunting develops over time. Percutaneous closure by embolization with either detachable balloons or coils or deployment of a vascular plug offers an effective and safe management for symptomatic patients.

Selective Left Internal Mammary Artery (LIMA) Graft Angiography Showing Iatrogenic Aortocoronary Arteriovenous Fistula.

(A) Free radial graft connecting the LIMA graft to the circumflex vein. CS , coronary sinus, LAD , left anterior descending coronary artery. (B) Large tortuous LIMA filling a large circumflex vein draining to the CS. (C) Percutaneous procedure with a catheter placed through the CS with the GuideLiner XL catheter (Vascular Solutions Inc., Minneapolis, Minnesota) extending beyond the catheter tip to the level of the radial graft–vein anastomosis. Circ, circumflex. (D) The Amplatzer vascular plug II at the level of LIMA–radial graft anastomosis. (E) Deployment of the Amplatzer vascular plug II. (F) Amplatzer vascular plug II in place with no residual flow from the LIMA to the circumflex vein.

Percutaneous Plugging of an Ascending Aortic Pseudoaneurysm

Ravinay Bhindi, MBBS, PhD

James Newton, MB ChB

Neil Wilson, MBBS

Oliver J. Ormerod, DM

A 76-year-old woman presented to hospital with a 1-month history of progressively worsening central chest pain. Her medical history was remarkable for a previous aortic valve replacement with an ascending aortic interposition graft 10 years earlier.

A computed tomography (CT) scan showed a large ascending aortic pseudoaneurysm with aortic communication through a defect at the superior aspect of the structure, below the level of the innominate vessels. Given the position of the pseudoaneurysm, the risk of repeat sternotomy was thought too high. Furthermore, the abdominal aorta was severely diseased and tortuous, making potential delivery of a covered stent difficult. It was therefore decided to attempt to close the mouth of the defect percutaneously.

Vascular access was achieved via the right brachial artery, and aortography showed moderate dehiscence at the posterior aspect of the superior margin of the interposition graft ( Fig. 7.21 A, Online Video 7.14 ). Adjuvant intracardiac echocardiography (ICE) was performed with the imaging catheter in the superior vena cava and showed a leak from the true aortic lumen into the false cavity ( Fig. 7.21 B). A 6F Judkins Right catheter was used with a 0.035-inch exchange-length wire to enter the defect, and contrast injection through the catheter further defined the anatomy of the cavity ( Fig. 7.21 C). Balloon sizing was performed with a 10-mm Cristal balloon ( Fig. 7.21 C), and a 7F Amplatzer TorqVue sheath was then used to deliver a 10-mm Amplatzer atrial septal defect device. This resulted in immediate reduction in flow into the defect by repeat aortography and ICE ( Fig. 7.21 D–E; Online Videos 7.15 and7.16 ). A second CT scan 2 days later confirmed obliteration of the defect and thrombosis of the cavity ( Fig. 7.21 G).

Images Illustrating Percutaneous Closure of the Aortic Pseudoaneurysm.

(A) Ascending thoracic aortography performed via the right brachial artery shows a leak ( solid arrow ) into a pseudoaneurysm cavity. An intracardiac echocardiography (ICE) probe ( dashed arrow ) is shown in the superior vena cava. (B) The ICE appearances of the pseudoaneurysm cavity, which are partly thrombosed ( T ). Blood is seen flowing through the defect in the aortic wall ( arrow ), from the true aortic lumen ( Ao ) into the false cavity. (C) Contrast opacification of the pseudoaneurysm cavity ( arrow ) via a Judkins Right catheter placed inside the defect shows its large size. (D) Balloon sizing ( arrow ) of the defect, showing the position of the orifice of the cavity. (E) An Amplatzer atrial septal defect (ASD) device ( arrow ) is shown deployed across the defect with a second aortogram showing no significant filling of the pseudoaneurysm. (F) An ICE showing position of the device across the defect with abolition of flow on color flow Doppler. Organizing thrombus ( T ) is also seen within the pseudocavity. (G) Computed tomography scan demonstrating thrombosis of the pseudocavity ( dotted arrow ) with the ASD occlusion device ( solid arrow ) seen in position (the true lumen of the ascending thoracic aorta is shown by the dashed arrow ).

Focal percutaneous sealing of ascending thoracic aneurysms has been successfully used previously by others ; however, to our knowledge this is the first case to use the brachial access approach in the setting of previous aortic graft surgery with adjuvant ICE imaging. In cases where surgical correction is deemed too high-risk and stent coverage not feasible, such an approach can be considered.

Inferior Vena Cava Filter Thrombosis and Suprarenal Caval Stenosis: A Double Whammy

Mohamad Alkhouli, MD

Irfan Shafi, MD

Riyaz Bashir, MBBS

Inferior vena cava (IVC) thrombosis associated with filters is not uncommon in clinical practice. However, suprarenal extension of the thrombosis to the hepatic segment of the IVC is very rare, particularly in the absence of renal or hepatic tumors. Benign intrinsic IVC stenosis is a rare anomaly that has been associated with IVC thrombosis. We describe a case of extensive IVC thrombosis secondary to perihepatic IVC stenosis (documented by intravascular ultrasound [IVUS]) and a permanent IVC filter, which was successfully treated by endovascular techniques.

A 38-year-old male smoker presented with back pain and left leg swelling for 1 week. He had no medical or surgical history except for a motor vehicle accident 18 years previously, which led to left hip surgery and a prophylactic IVC filter placement. He was not taking any medications and had no family history of venous thromboembolism or hypercoagulable state. On physical examination, he had a markedly swollen and tender left leg and thigh with moderate skin erythema. He had normal pulses and no evidence of skin breakdown or ulceration. Duplex ultrasound showed acute deep vein thrombosis (DVT) of the left common femoral vein, and no evidence of DVT in the right leg. A computed tomography venogram showed massive IVC filter–associated thrombosis with totally occluded infrarenal IVC and suprarenal extension of the thrombus all the way up to hepatic segment. It also suggested a possible stenosis of the perihepatic IVC ( Fig. 7.22 ).

Computed Tomography Scan (Coronal and Lateral Views) Showing Massive Inferior Vena Cava Thrombosis Extending to the Hepatic Segment.

Upper inset is a cross-sectional view showing severe stenosis/near obliteration of the inferior vena cava. Lower inset is a cross-sectional view of the suprarenal inferior vena cava showing severe thrombosis.

In view of the severe and disabling symptoms in this young man, we decide to proceed with catheter-directed thrombolysis (CDT). A 50-cm EKOS catheter (EKOS, Bothell, Washington) was positioned from the hepatic segment of the IVC to the left femoral vein, and tissue plasminogen activator was infused over 16 h. While undergoing CDT, he noted complete resolution of his back pain. Post-CDT venography showed complete lysis of the thrombus above the IVC filter and a severe stenosis of the IVC just below the hepatic veins ( Fig. 7.23 , Online Video 7.17 ). The latter was confirmed by IVUS, as well as pressure gradient measurement ( Fig. 7.23 , Online Video 7.18 ). Minimal clot lysis was noted below the filter and was treated with mechanical thrombectomy followed by balloon angioplasty and stenting. In view of the IVUS findings and a pressure gradient of 18 mm Hg across the lesion in the hepatic IVC, we went on to treat it with a self-expanding (24 × 70 mm) wall stent with excellent angiographic and hemodynamic results ( Fig. 7.23 ). On 1-week follow-up, he had complete resolution of his lower extremity swelling and pain. At 6 months, he continued to be asymptomatic with patent stents and no evidence of recurrent DVT ( Fig. 7.24 ). In most cases, IVC filter–related thrombosis is seen below or a few centimeters above the filter. Extension of clot all the way up to the hepatic segment is usually seen in patients with hepatic or nephric tumors, which either invade or compress the IVC. ^, Benign intrinsic IVC stenosis is very rare (<0.1%) but is known to be associated with massive caval thrombosis. The most common location for this stenosis is around the perihepatic region of the IVC. The exact pathogenesis of such lesions is not well understood. Some authors suggest that it is a congenital anomaly related to abnormal fusion of the vitelline and the subcardinal veins in utero, whereas others propose that it is an acquired condition caused by healed thrombosis producing intravascular membrane or web formations.

Inferior Vena Cava Stenosis Below the Hepatic Veins.

(A) Cavogram (OnlineVideo 7.17 ) and intravascular ultrasound (Online Video 7.18 ) after catheter-directed thrombolysis showing inferior vena cava stenosis below the hepatic veins. (B) Poststent imaging showed excellent angiographic and ultrasonographic results. Insets are intravascular ultrasound cross-sectional views of the inferior vena cava before (A) and after (B) stenting.

Patent Stent at 3 Months.

Computed tomography scan at 3 months showing a well-opposed patent stent in the suprarenal inferior vena cava. Inset is a cross-sectional view.

This case suggests that patients with IVC stenosis who are undergoing IVC filter placement may be at particularly high risk for extensive IVC thrombosis, including very high suprarenal extension. Hence there is a need for the very judicious use of IVC filters in these patients and timely retrieval if they are absolutely indicated. In addition, this case highlights the feasibility of catheter-based treatment of this rare but debilitating complication.

Neurovascular Rescue for Thrombus-Related Embolic Stroke During Transcatheter Aortic Valve Implantation

Pablo Salinas, MD

Raul Moreno, MD, PhD

Remedios Frutos, MD

Jose Luis Lopez-Sendon, MD, PhD

An 88-year-old woman with critical aortic stenosis was scheduled for transfemoral transcatheter aortic valve implantation (TAVI). She received preprocedural aspirin plus clopidogrel, and 100 IU/kg unfractionated heparin during the procedure. The procedure was uneventful, and the balloon-expandable valve was successfully deployed. After deflating the balloon, an echo-dense mobile mass was seen in the left ventricular outflow tract ( Fig. 7.25 , Online Video 7.19 ), probably attached to the intraventricular portion of the guidewire. This mass was not present after valvuloplasty, so torn leaflets from the native valve were unlikely. Activated clotting time was 270 s. When the balloon catheter and guidewire were withdrawn, the mass disappeared.

Transesophageal Echocardiogram After Prosthesis Deployment.

Echo-dense mobile mass ( arrow ) in the left ventricular outflow tract after transcatheter valve deployment. This is best seen in Online Video 7.19 .

The patient remained stable with nice prosthesis gradients. All pulses were palpable, but after prompt reversal of anesthesia, a complete left hemiparesis was found. A brain computed tomography scan confirmed a large right middle cerebral artery (RMCA) stroke. Immediate mechanical neurovascular rescue was attempted. In the initial angiography, there was a complete occlusion of the M1 branch of the RMCA with thrombus in the A1 branch ( Fig. 7.26 ). Mechanical thrombectomy was performed with a Solitaire AB device (ev3, Endovascular Inc., Plymouth, Minnesota), extracting a 13-mm thrombus ( Fig. 7.27 ). The control angiogram shows complete RMCA reperfusion ( Fig. 7.28 ). The neurologic deficit improved to modified Rankin scale 1 at discharge and remained unchanged after 6 months of follow-up.

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