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Endovascular Repair of an Ascending Aortic Pseudoaneurysm With a Septal Occluder Device: Mid-Term Follow-Up
Endovascular Repair of an Ascending Aortic Pseudoaneurysm With a Septal Occluder Device: Mid-Term Follow-Up Jacques Kpodonu, MD, Grayson H. Wheatley III, MD, Venkatesh G. Ramaiah, MD, Julio A. Rodriguez-Lopez, MD, Robert K. Strumpf, MD, and Edward B. Diethrich, MD
Ascending pseudoaneurysm is an infrequent complication of ascending aortic surgery. Redo operations are often associated with a high surgical morbidity and mortality. Endovascular management of ascending aortic pathologies with endoluminal graft therapies are challenging due to short landing zones and the fear of flow obstruction to the coronaries and brachiocephalic circu-
lation. We report mid-term follow-up of the management of an ascending aortic pseudoaneurysm using a an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) in a 51-year-old man considered at high risk for conventional open surgical repair. (Ann Thorac Surg 2008;85:349 –51) © 2008 by The Society of Thoracic Surgeons
A
x-ray film performed at his 5-month checkup revealed a mass on the ascending aorta suspicious for an ascending aorta pseudoaneurysm. A computed tomographic scan of the chest was performed (Figs 1A, 1B), which demonstrated a large pseudoaneurysm arising on the anterior aspect of the ascending aorta measuring 7.6 cm ⫻ 8.0 cm; it was believed to have originated from the cardioplegia site. The neck of the pseudoaneurysm was measured at 8 mm wide. The patient was believed to be at extreme risk for open surgical repair. After discussion with the patient, family consent was given for a total endovascular approach with an institutional investigational device protocol. An open retrograde cannulation of the left common femoral artery was performed with an 18-gauge needle. After 5,000 units of heparin was given to the patient, a 0.035-inch soft tip, angled glidewire was advanced under fluoroscopic visualization into the ascending aorta and was exchanged for a 9-French sheath. Percutaneous retrograde cannulation of the right common femoral artery was similarly performed and a 5-French sheath was placed. A 5-French pigtail angiographic catheter was advanced through the right common femoral artery sheath over the glidewire into the ascending aorta, and an aortogram was performed that demonstrated the ascending aorta and the right and left coronary arteries (Fig 2A). The 0.035-inch soft tip, angled glide wire was then manipulated into the pseudoaneurysm sac with the help of a guiding catheter under fluoroscopy with a contrast angiogram, which demonstrated the pseudoaneurysm (Fig 2B). A 7-French intravascular ultrasound probe (Volcano Therapeutics, Rancho Cordova, CA) was
scending aortic pseudoaneurysms are rare and occur infrequently from anastomotic dehiscence of suture lines and cannulation sites from previous aortic surgery [1]. Traditional open surgical repair requires a redo sternotomy cardiopulmonary bypass and infrequently hypothermic circulatory arrest. Hybrid interventions have been successfully used to treat such high surgical risk patients. We describe the successful endovascular repair of an ascending aortic pseudoaneurysm in a 51-year-old man with an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN). At 18 months post-procedure, he continues to do well with marked reduction in the pseudoaneurysm sac.
Technique Methicillin-sensitive Staphylococcus aureus infective endocarditis developed in the mitral valve apparatus of a 51-year-old man with a past medical history significant for atrial fibrillation and postoperative pacemaker insertion. Thus, the apparatus required replacement with a mechanical valve prosthesis. His postoperative course was complicated by sternal wound dehiscence requiring extensive debridement of the sternum with a pectoral muscle flap reconstruction. He had fever and chills develop with positive blood cultures 2 months post-mitral valve replacement positive for methicillin-resistant S. aureus. He was diagnosed with prosthetic valve infective endocarditis. He underwent a second mitral valve replacement using a porcine valve through a right thoracotomy and seemed to be doing well at 5 months follow-up when he complained of chest discomfort. A chest Accepted for publication June 18, 2007. Address correspondence to Dr Kpodonu, Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Institute, 2632 N 20th St, Phoenix, AZ 85006; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Wheatley discloses a financial relationship with W. L. Gore and Associates.
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.06.053
FEATURE ARTICLES
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, Arizona
350
HOW TO DO IT KPODONU ET AL ASCENDING AORTA PSEUDOANEURYSM, SEPTAL OCCLUDER DEVICE
Ann Thorac Surg 2008;85:349 –51
Fig 1. (A) Axial computed tomography and (B) 64-slice computed tomographic scan demonstrate an ascending aortic pseudoaneurysm with thrombus and a neck of 8 mm. FEATURE ARTICLES
advanced through the left common femoral artery sheath and positioned in the pseudoaneurysm sac under fluoroscopic visualization. The pseudoaneurysm neck diameter was measured at 8 mm and was positioned about 2 cm distal to the origin of the right coronary artery. The left groin sheath was exchanged to a 9-French ⫻ 60 cm (Cook Medical Inc, Bloomington, IN) sheath over a 0.035inch extra stiff wire. An appropriately sized Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) was selected and deployed across the aortic pseudoaneurysm under fluoroscopic visualization. A completion aortogram demonstrated satisfactory positioning of the occluder device with no identifiable leak. Sheaths and wires were removed, repair of the left common femoral artery was performed, and a closure device was deployed to the right common femoral artery. The patient made an uneventful recovery with a postoperative computed tomographic scan (Fig 3A) demonstrating complete exclusion of the neck of the pseudoaneurysm. A computed tomographic scan was performed at 5 months, which demonstrated regression of the pseudoaneurysm sac (Fig
3B). The patient continues to do well at 18 months follow-up.
Comment Pseudoaneurysms of the ascending aorta arise from cannulation sites from aortic perfusion catheters, cardioplegia cannulation sites, origin of saphenous vein grafts conduits, and aortotomy sites from aortic valve replacement during cardiopulmonary bypass. Pseudoaneurysms of the ascending aorta and aortic arch are difficult to treat, and open surgical techniques are associated with considerable morbidity and mortality due to redo median sternotomies. The application of thoracic aortic endografting to treat thoracic aortic disease has been associated with a decrease in morbidity and mortality, decrease in rates of paraplegia, decrease in hospital and intensive care unit stays, decrease in blood transfusions, and a more rapid recovery compared with open surgical techniques [2]. Total endovascular management of the ascending aorta (although an attractive option) is still in its infancy
Fig 2. (A) Angiogram demonstrates the right coronary artery (RCA) and left coronary artery (LCA), (B) as well as the ascending aorta pseudoaneurysm (see arrow).
HOW TO DO IT KPODONU ET AL ASCENDING AORTA PSEUDOANEURYSM, SEPTAL OCCLUDER DEVICE
351
Fig 3. (A) Postoperative axial computed tomographic scan demonstrates exclusion of the ascending aortic pseudoaneurysm with an Amplatz occluder (see arrow) (AGA Medical Corp, Golden Valley, MN), (B) which is well positioned shown by a 5-month follow-up computed tomographic scan demonstrating thrombosis and shrinkage of the pseudoaneurysm sac.
[3] and requires an in-depth knowledge of the surgical anatomy. The complex anatomy of the sinotubular junction, the variations in the aortic pathology, and the presentation of disease all require a unique approach to each patient. Most ascending aortic aneurysms are related to medial degeneration and require elective replacement when they are symptomatic or when the diameter is greater than 6.0 cm in diameter. There is no commercially available endoluminal graft for the management of ascending aortic pathology. Application of endoluminal graft to the ascending aorta has to take into account the short landing zones and the possibility of flow obstruction to the coronary artery circulation and brachiocephalic vessels. Customized grafts incorporating Gianturco Z stents (Cook Inc, Bloomington, IN) and polytetrafluoroethylene have been constructed to create devices of varying diameters and lengths suitable for use in the ascending aorta. Combination of endovascular techniques using coil embolization [4], endoluminal grafts, and septa occluders [5] have been described to treat pseudoaneurysms of the ascending aorta. The application of an Amplatz atrial septal occluder device (Cook Inc, Bloomington, IN) to exclude a pseudoaneurysm of the ascending aorta is a novel technique that requires a discrete neck for deployment. Intravascular ultrasound is a useful tool that aids in
determining the exact diameter of the neck for careful selection of the appropriately sized device. In conclusion, with the advancement of imaging and improvement in device technology, the ascending aorta may become more amenable to endovascular repair techniques such as endografts. Close follow-up of such patients should be done under close surveillance protocols.
References 1. Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pesudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138 – 43. 2. Makaroun MS, Dillavou ED, Kes ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the Gore TAG thoracic endoprosthesis. J Vasc Surg 2005;41:1–9. 3. Mussa FF, Le Maire SA, Bozinovski J, Coselli JS. An entirely endovascular approach to the repair of an ascending aortic pseudo aneurysm. J Thorac Cardiovasc Surg 2007;133:562–3. 4. Lin PH, Busch RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of n ascending aortic pseudo aneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg 2001;34:939 – 42. 5. Komanapalli CB, Burch G, Tripathy U, Slater MS, Song HK. Percutaneous repair of an ascending aortic pseudoaneurysm with a septal occluder device. J Thorac Cardiovasc Surg 2005;130:603– 4.
FEATURE ARTICLES
Ann Thorac Surg 2008;85:349 –51
Ascending pseudoaneurysm is an infrequent complication of ascending aortic surgery. Redo operations are often associated with a high surgical morbidity and mortality. Endovascular management of ascending aortic pathologies with endoluminal graft therapies are challenging due to short landing zones and the fear of flow obstruction to the coronaries and brachiocephalic circu-
lation. We report mid-term follow-up of the management of an ascending aortic pseudoaneurysm using a an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) in a 51-year-old man considered at high risk for conventional open surgical repair. (Ann Thorac Surg 2008;85:349 –51) © 2008 by The Society of Thoracic Surgeons
A
x-ray film performed at his 5-month checkup revealed a mass on the ascending aorta suspicious for an ascending aorta pseudoaneurysm. A computed tomographic scan of the chest was performed (Figs 1A, 1B), which demonstrated a large pseudoaneurysm arising on the anterior aspect of the ascending aorta measuring 7.6 cm ⫻ 8.0 cm; it was believed to have originated from the cardioplegia site. The neck of the pseudoaneurysm was measured at 8 mm wide. The patient was believed to be at extreme risk for open surgical repair. After discussion with the patient, family consent was given for a total endovascular approach with an institutional investigational device protocol. An open retrograde cannulation of the left common femoral artery was performed with an 18-gauge needle. After 5,000 units of heparin was given to the patient, a 0.035-inch soft tip, angled glidewire was advanced under fluoroscopic visualization into the ascending aorta and was exchanged for a 9-French sheath. Percutaneous retrograde cannulation of the right common femoral artery was similarly performed and a 5-French sheath was placed. A 5-French pigtail angiographic catheter was advanced through the right common femoral artery sheath over the glidewire into the ascending aorta, and an aortogram was performed that demonstrated the ascending aorta and the right and left coronary arteries (Fig 2A). The 0.035-inch soft tip, angled glide wire was then manipulated into the pseudoaneurysm sac with the help of a guiding catheter under fluoroscopy with a contrast angiogram, which demonstrated the pseudoaneurysm (Fig 2B). A 7-French intravascular ultrasound probe (Volcano Therapeutics, Rancho Cordova, CA) was
scending aortic pseudoaneurysms are rare and occur infrequently from anastomotic dehiscence of suture lines and cannulation sites from previous aortic surgery [1]. Traditional open surgical repair requires a redo sternotomy cardiopulmonary bypass and infrequently hypothermic circulatory arrest. Hybrid interventions have been successfully used to treat such high surgical risk patients. We describe the successful endovascular repair of an ascending aortic pseudoaneurysm in a 51-year-old man with an Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN). At 18 months post-procedure, he continues to do well with marked reduction in the pseudoaneurysm sac.
Technique Methicillin-sensitive Staphylococcus aureus infective endocarditis developed in the mitral valve apparatus of a 51-year-old man with a past medical history significant for atrial fibrillation and postoperative pacemaker insertion. Thus, the apparatus required replacement with a mechanical valve prosthesis. His postoperative course was complicated by sternal wound dehiscence requiring extensive debridement of the sternum with a pectoral muscle flap reconstruction. He had fever and chills develop with positive blood cultures 2 months post-mitral valve replacement positive for methicillin-resistant S. aureus. He was diagnosed with prosthetic valve infective endocarditis. He underwent a second mitral valve replacement using a porcine valve through a right thoracotomy and seemed to be doing well at 5 months follow-up when he complained of chest discomfort. A chest Accepted for publication June 18, 2007. Address correspondence to Dr Kpodonu, Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Institute, 2632 N 20th St, Phoenix, AZ 85006; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Wheatley discloses a financial relationship with W. L. Gore and Associates.
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.06.053
FEATURE ARTICLES
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, Arizona
350
HOW TO DO IT KPODONU ET AL ASCENDING AORTA PSEUDOANEURYSM, SEPTAL OCCLUDER DEVICE
Ann Thorac Surg 2008;85:349 –51
Fig 1. (A) Axial computed tomography and (B) 64-slice computed tomographic scan demonstrate an ascending aortic pseudoaneurysm with thrombus and a neck of 8 mm. FEATURE ARTICLES
advanced through the left common femoral artery sheath and positioned in the pseudoaneurysm sac under fluoroscopic visualization. The pseudoaneurysm neck diameter was measured at 8 mm and was positioned about 2 cm distal to the origin of the right coronary artery. The left groin sheath was exchanged to a 9-French ⫻ 60 cm (Cook Medical Inc, Bloomington, IN) sheath over a 0.035inch extra stiff wire. An appropriately sized Amplatz septal occluder (AGA Medical Corp, Golden Valley, MN) was selected and deployed across the aortic pseudoaneurysm under fluoroscopic visualization. A completion aortogram demonstrated satisfactory positioning of the occluder device with no identifiable leak. Sheaths and wires were removed, repair of the left common femoral artery was performed, and a closure device was deployed to the right common femoral artery. The patient made an uneventful recovery with a postoperative computed tomographic scan (Fig 3A) demonstrating complete exclusion of the neck of the pseudoaneurysm. A computed tomographic scan was performed at 5 months, which demonstrated regression of the pseudoaneurysm sac (Fig
3B). The patient continues to do well at 18 months follow-up.
Comment Pseudoaneurysms of the ascending aorta arise from cannulation sites from aortic perfusion catheters, cardioplegia cannulation sites, origin of saphenous vein grafts conduits, and aortotomy sites from aortic valve replacement during cardiopulmonary bypass. Pseudoaneurysms of the ascending aorta and aortic arch are difficult to treat, and open surgical techniques are associated with considerable morbidity and mortality due to redo median sternotomies. The application of thoracic aortic endografting to treat thoracic aortic disease has been associated with a decrease in morbidity and mortality, decrease in rates of paraplegia, decrease in hospital and intensive care unit stays, decrease in blood transfusions, and a more rapid recovery compared with open surgical techniques [2]. Total endovascular management of the ascending aorta (although an attractive option) is still in its infancy
Fig 2. (A) Angiogram demonstrates the right coronary artery (RCA) and left coronary artery (LCA), (B) as well as the ascending aorta pseudoaneurysm (see arrow).
HOW TO DO IT KPODONU ET AL ASCENDING AORTA PSEUDOANEURYSM, SEPTAL OCCLUDER DEVICE
351
Fig 3. (A) Postoperative axial computed tomographic scan demonstrates exclusion of the ascending aortic pseudoaneurysm with an Amplatz occluder (see arrow) (AGA Medical Corp, Golden Valley, MN), (B) which is well positioned shown by a 5-month follow-up computed tomographic scan demonstrating thrombosis and shrinkage of the pseudoaneurysm sac.
[3] and requires an in-depth knowledge of the surgical anatomy. The complex anatomy of the sinotubular junction, the variations in the aortic pathology, and the presentation of disease all require a unique approach to each patient. Most ascending aortic aneurysms are related to medial degeneration and require elective replacement when they are symptomatic or when the diameter is greater than 6.0 cm in diameter. There is no commercially available endoluminal graft for the management of ascending aortic pathology. Application of endoluminal graft to the ascending aorta has to take into account the short landing zones and the possibility of flow obstruction to the coronary artery circulation and brachiocephalic vessels. Customized grafts incorporating Gianturco Z stents (Cook Inc, Bloomington, IN) and polytetrafluoroethylene have been constructed to create devices of varying diameters and lengths suitable for use in the ascending aorta. Combination of endovascular techniques using coil embolization [4], endoluminal grafts, and septa occluders [5] have been described to treat pseudoaneurysms of the ascending aorta. The application of an Amplatz atrial septal occluder device (Cook Inc, Bloomington, IN) to exclude a pseudoaneurysm of the ascending aorta is a novel technique that requires a discrete neck for deployment. Intravascular ultrasound is a useful tool that aids in
determining the exact diameter of the neck for careful selection of the appropriately sized device. In conclusion, with the advancement of imaging and improvement in device technology, the ascending aorta may become more amenable to endovascular repair techniques such as endografts. Close follow-up of such patients should be done under close surveillance protocols.
References 1. Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pesudoaneurysm of the ascending aorta following cardiac surgery. Chest 1988;93:138 – 43. 2. Makaroun MS, Dillavou ED, Kes ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the Gore TAG thoracic endoprosthesis. J Vasc Surg 2005;41:1–9. 3. Mussa FF, Le Maire SA, Bozinovski J, Coselli JS. An entirely endovascular approach to the repair of an ascending aortic pseudo aneurysm. J Thorac Cardiovasc Surg 2007;133:562–3. 4. Lin PH, Busch RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of n ascending aortic pseudo aneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg 2001;34:939 – 42. 5. Komanapalli CB, Burch G, Tripathy U, Slater MS, Song HK. Percutaneous repair of an ascending aortic pseudoaneurysm with a septal occluder device. J Thorac Cardiovasc Surg 2005;130:603– 4.
FEATURE ARTICLES
Ann Thorac Surg 2008;85:349 –51