Case Report
Endovascular Closure of Ascending Aortic Pseudoaneurysm With a Type II Amplatzer Vascular Plug
Vascular and Endovascular Surgery 2014, Vol. 48(4) 329-332 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414522329 ves.sagepub.com
Diederick W. De Boo, MD, PhD1, Nigel Mott, MD1, Helen Kavnoudias, PhD1, Antony Walton, MD2, and Stuart M. Lyon, MD1
Abstract A 71-year-old man initially presented with an asymptomatic, incidentally detected ascending aortic pseudoaneurysm 25 years following aortic root repair with mechanical aortic valve replacement. This pseudoaneurysm was previously treated with coil embolization but due to coil impaction it reopened 8 years later. Endovascular closure of the pseudoaneurysm was achieved with the off-label use of a type II Amplatzer vascular plug. Keywords endovascular, ascending aorta pseudoaneurysm, Amplatzer vascular plug
Introduction
Case Report
Ascending aortic pseudoaneurysms are a rare but potentially lethal complication following various types of surgery involving the ascending aorta. Less than 0.5% of all patients undergoing cardiac surgery will develop pseudoaneuryms either at the aortic canulation/aortomy site or at the aortic anastomosis.1 Other, less common causes for ascending aortic pseudoaneurysms include trauma and infective aortitis. Pseudoaneurysms can be asymptomatic and incidentally detected on cross-sectional imaging, present with signs of mass effect on surrounding structures, for example, trachea or esophagus, or present with signs of hemorrhage. In a case series reported by Malvindi et al, 53% (n ¼ 23) of the patients with an ascending aortic pseudoaneurysm were asymptomatic.2 Conventional treatment includes surgical ligation or replacement of the ascending aorta with a graft. This is however accompanied with high morbidity and a reported mortality rate of 6.9%.2 An alternative for surgically high-risk patients is a less invasive, endovascular treatment. Several endovascular treatment options have been reported and include ascending aortic stent grafts, percutaneous coil embolization, direct thrombin injection, and off-label use of septal closure devices and vascular plugs.3-6 We report a successful closure of a reopened, asymptomatic ascending aortic pseudoaneurysm with the off-label use of a type II Amplatzer vascular plug (AVP) in a patient 8 years after closure with coil embolization and 33 years after the initial cardiac surgery.
A 72-year-old male with a history of aortic root repair with mechanical aortic valve replacement (mAVR) in the late 1980s was found to have an asymptomatic ascending aortic pseudoaneurysm which was detected 25 years after the initial cardiac surgery. It was an incidental finding during the workup for the treatment of colorectal cancer. At that time, this pseudoaneurysm was successfully treated with percutaneous coil embolization. While being treated for his colorectal cancer, he was lost to follow-up for his ascending aorta pseudo-aneurysm. A chest computed tomography (CT) performed 8 years after the percutaneous closure showed the coils had impacted, the ascending aortic pseudoaneurysm had reopened, and that it had grown in diameter. The patient was referred to our tertiary center for a possible, second endovascular treatment. The patient was asymptomatic and clinically in good condition. Colorectal cancer with solitary liver metastasis was considered cured by surgery and chemotherapy. Prescribed medication included warfarin for the mechanical aortic valve. Our workup for a possible endovascular treatment included an electrocardiogram (ECG)-gated CT angiogram of the thoracic
1
Department of Radiology, Alfred Health, Melbourne, Victoria, Australia Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
2
Corresponding Author: Diederick W. De Boo, Department of Radiology, Alfred Health, 55 Commercial Road, Prahran, Melbourne, 3181 Victoria, Australia. Email: [email protected]
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
330
Vascular and Endovascular Surgery 48(4)
Figure 1. Preprocedural imaging of the ascending aortic pseudoaneurysm and neck with computed tomography (CT; A and B), transthoracic ultrasound (C), and angiography (D). Ao indicates aorta; psA, pseudoaneurysm.
aorta, thoracic angiogram, and transthoracic ultrasound. Figure 1 shows the pseudoaneurysm that originates at the distal anastomis between the graft and the aortic arch on various imaging modalities. The distance between the neck of the aneurysm and the innominate artery is around 3 cm. The pseudoaneurysm reopened at its cranial portion, and therefore the neck was located at the dome. Its diameter varied between 6 and 8 mm on the preprocedural imaging. On the day of the procedure, informed consent was obtained and antibiotic prophylaxis was administered (1 g cephazolin intravenous). Warfarin was not seized and the preprocedural international normalized ratio was 2.1. Via a right common femoral artery approach, an 8F guiding sheath was advanced through the neck into the pseudoaneurysm. A 10-mm diameter type II AVP (St Jude Medical, St Paul, Minnesota) was positioned in the neck of the pseudoaneurysm (Figure 2). The unconstrained device length of this size AVP is 7 mm. In order
to prevent embolization of the AVP and minimize the amount of foreign body in the aortic lumen, 2 disks were placed in the pseudoaneurysm and 1 disk in the aortic lumen. A control angiogram through the sheath confirmed adequate positioning and the AVP was successfully deployed (Figure 2). The sheath was removed and hemostasis was obtained with a closure device (Starclose; Abbott, Abbott Park, Illinois). The patient was discharged the following day without postprocedural complications. An outpatient ECG-gated CT angiogram 1 month after the procedure showed successful closure of the pseudoaneurysm and the position of the AVP was unchanged and adequate (Figure 3).
Discussion Surgical repair of the ascending thoracic aorta pseudo-aneurysms, either asymptomatic or symptomatic, is still considered the
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
De Boo et al
331
Figure 2. Procedure: (A) ascending aorta angiogram, (B) angiogram with guide catheter in the pseudoaneurysm, (C) control angiogram after positioning of the type II Amplatzer vascular plug (AVP) and prior to deployment, and (D) after deployment of the AVP.
treatment of choice. However, this procedure is associated with substantial morbidity and a mortality rate of circa 7%.2 Several less invasive endovascular approaches for closure of these pseudoaneurysms have been reported, especially in surgical high-risk patients.3-6 Our patient initially presented with an incidentally detected pseudoaneurysm of the ascending thoracic aorta, 25 years following aortic root repair and mAVR. At that time, coil embolization was performed with technically good result. However, during follow-up the aneurysm reopened and the patient was referred 8 years after the coil embolization for a possible second percutaneous closure. Preprocedural imaging showed that the pseudoaneurysm had reopened at its cranial portion. The neck was located at the dome of the pseudoaneurysm and its diameter was 6 to 8 mm on the various imaging modalities. Covering the neck with a stent graft was not considered possible for 2 reasons: first, there was an acute change in
diameter between the elongated, dilated aortic arch and the ascending aorta graft. Inadequate seal leading to a type I endoleak was assumed to be very likely. Second, the mechanical aortic valve prohibited a stable wire position for the stent graft delivery. The location of the neck and site of reopening increased the risk of coil migration during the procedure and therefore prohibited a second coil embolization. Several case reports have been published on the off-label use of atrial septal defect (ASD) and membranous ventricular septal defect (mVSD) occluders for ascending aortic pseudoaneurysm.6 These devices consist of 2 disks with a connecting waist that corresponds to the septal defect or neck diameter when used for percutaneous closure of pseudoaneurysms. An overall 86% (12 of 14) of technical success rate has been reported for these septal occluders.6 Depending on the size of the waist of the septal occluders, the disks are 4 to 8 mm larger in diameter. With the neck located at the
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
332
Vascular and Endovascular Surgery 48(4)
Figure 3. Postprocedural computed tomography (CT) angiogram (1 month) shows an unchanged, satisfactory position of the type II Amplatzer vascular plug with thrombosed ascending aortic pseudoaneurysm.
dome, we feared inadequate positioning with the use of either an ASD or a mVSD occluder. The type II AVP consists of 3 disks with a pin waist between both outer and the center disk. Positioning 2 disks in the pseudoaneurysm provided more stability and lowered the risk of device embolization that has been described in 2 patients where a septal occluder device was used.6 It should be noted however that both pseudoaneurysms treated were mycotic, whereas this was not the case in our patient. Consequently, we made the decision to use the type II AVP. Its successful use for the closure of an asymptomatic ascending aortic pseudoaneurysm has been described once before. This patient was treated 11 years after the initial cardiac surgery.7
Conclusions We present a successful endovascular closure of an ascending aortic pseudoaneurysm with the off-label use of a type II AVP. Although the long-term durability has not been established, this treatment is minimally invasive and can be considered as alternative to surgical correction, especially in high-risk patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thoracic Surg. 2000; 70(2):547-552. 2. Malvindi PG, van Putte BP, Heijmen RH, Schepens MAAM, Morshuis WJ. Reoperations for aortic false aneurysms after cardiac surgery. Ann Thorac Surg. 2010;90(5):1437-1443. 3. Zago AC, Saadi EK, Zago AJ. Endovascular approach to treat ascending aortic pseudoaneurysm in a patient with previous CABG and very high surgical risk. Catheter Cardiovasc Interv. 2011; 78(4):551-557. 4. Chapot R, Aymard A, Saint-Maurice JP, Bel A, Merland JJ, Houdart E. Coil embolization of an aortic arch false aneurysm. J Endovasc Ther. 2002;9(6):922-925. 5. Lin PH, Bush RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of an ascending aortic pseudoaneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg. 2001;34(5): 939-942. 6. Noble S, Ibrahim R. Embolization of an Amplatzer mVSD occluder device used for percutaneous closure of an ascending aortic pseudoaneurysm: case report and literature review. Catheter Cardiovasc Interv. 2012;79(2):334-338. 7. Scholtz W, Jategankar S, Haas NA. Successful interventional treatment of a retrosternal pseudoaneurysm of the ascending aorta with an Amplatzer vascular plug type II. J Invasive Cardiol. 2010;22(3): E44-E46.
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
Endovascular Closure of Ascending Aortic Pseudoaneurysm With a Type II Amplatzer Vascular Plug
Vascular and Endovascular Surgery 2014, Vol. 48(4) 329-332 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414522329 ves.sagepub.com
Diederick W. De Boo, MD, PhD1, Nigel Mott, MD1, Helen Kavnoudias, PhD1, Antony Walton, MD2, and Stuart M. Lyon, MD1
Abstract A 71-year-old man initially presented with an asymptomatic, incidentally detected ascending aortic pseudoaneurysm 25 years following aortic root repair with mechanical aortic valve replacement. This pseudoaneurysm was previously treated with coil embolization but due to coil impaction it reopened 8 years later. Endovascular closure of the pseudoaneurysm was achieved with the off-label use of a type II Amplatzer vascular plug. Keywords endovascular, ascending aorta pseudoaneurysm, Amplatzer vascular plug
Introduction
Case Report
Ascending aortic pseudoaneurysms are a rare but potentially lethal complication following various types of surgery involving the ascending aorta. Less than 0.5% of all patients undergoing cardiac surgery will develop pseudoaneuryms either at the aortic canulation/aortomy site or at the aortic anastomosis.1 Other, less common causes for ascending aortic pseudoaneurysms include trauma and infective aortitis. Pseudoaneurysms can be asymptomatic and incidentally detected on cross-sectional imaging, present with signs of mass effect on surrounding structures, for example, trachea or esophagus, or present with signs of hemorrhage. In a case series reported by Malvindi et al, 53% (n ¼ 23) of the patients with an ascending aortic pseudoaneurysm were asymptomatic.2 Conventional treatment includes surgical ligation or replacement of the ascending aorta with a graft. This is however accompanied with high morbidity and a reported mortality rate of 6.9%.2 An alternative for surgically high-risk patients is a less invasive, endovascular treatment. Several endovascular treatment options have been reported and include ascending aortic stent grafts, percutaneous coil embolization, direct thrombin injection, and off-label use of septal closure devices and vascular plugs.3-6 We report a successful closure of a reopened, asymptomatic ascending aortic pseudoaneurysm with the off-label use of a type II Amplatzer vascular plug (AVP) in a patient 8 years after closure with coil embolization and 33 years after the initial cardiac surgery.
A 72-year-old male with a history of aortic root repair with mechanical aortic valve replacement (mAVR) in the late 1980s was found to have an asymptomatic ascending aortic pseudoaneurysm which was detected 25 years after the initial cardiac surgery. It was an incidental finding during the workup for the treatment of colorectal cancer. At that time, this pseudoaneurysm was successfully treated with percutaneous coil embolization. While being treated for his colorectal cancer, he was lost to follow-up for his ascending aorta pseudo-aneurysm. A chest computed tomography (CT) performed 8 years after the percutaneous closure showed the coils had impacted, the ascending aortic pseudoaneurysm had reopened, and that it had grown in diameter. The patient was referred to our tertiary center for a possible, second endovascular treatment. The patient was asymptomatic and clinically in good condition. Colorectal cancer with solitary liver metastasis was considered cured by surgery and chemotherapy. Prescribed medication included warfarin for the mechanical aortic valve. Our workup for a possible endovascular treatment included an electrocardiogram (ECG)-gated CT angiogram of the thoracic
1
Department of Radiology, Alfred Health, Melbourne, Victoria, Australia Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
2
Corresponding Author: Diederick W. De Boo, Department of Radiology, Alfred Health, 55 Commercial Road, Prahran, Melbourne, 3181 Victoria, Australia. Email: [email protected]
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
330
Vascular and Endovascular Surgery 48(4)
Figure 1. Preprocedural imaging of the ascending aortic pseudoaneurysm and neck with computed tomography (CT; A and B), transthoracic ultrasound (C), and angiography (D). Ao indicates aorta; psA, pseudoaneurysm.
aorta, thoracic angiogram, and transthoracic ultrasound. Figure 1 shows the pseudoaneurysm that originates at the distal anastomis between the graft and the aortic arch on various imaging modalities. The distance between the neck of the aneurysm and the innominate artery is around 3 cm. The pseudoaneurysm reopened at its cranial portion, and therefore the neck was located at the dome. Its diameter varied between 6 and 8 mm on the preprocedural imaging. On the day of the procedure, informed consent was obtained and antibiotic prophylaxis was administered (1 g cephazolin intravenous). Warfarin was not seized and the preprocedural international normalized ratio was 2.1. Via a right common femoral artery approach, an 8F guiding sheath was advanced through the neck into the pseudoaneurysm. A 10-mm diameter type II AVP (St Jude Medical, St Paul, Minnesota) was positioned in the neck of the pseudoaneurysm (Figure 2). The unconstrained device length of this size AVP is 7 mm. In order
to prevent embolization of the AVP and minimize the amount of foreign body in the aortic lumen, 2 disks were placed in the pseudoaneurysm and 1 disk in the aortic lumen. A control angiogram through the sheath confirmed adequate positioning and the AVP was successfully deployed (Figure 2). The sheath was removed and hemostasis was obtained with a closure device (Starclose; Abbott, Abbott Park, Illinois). The patient was discharged the following day without postprocedural complications. An outpatient ECG-gated CT angiogram 1 month after the procedure showed successful closure of the pseudoaneurysm and the position of the AVP was unchanged and adequate (Figure 3).
Discussion Surgical repair of the ascending thoracic aorta pseudo-aneurysms, either asymptomatic or symptomatic, is still considered the
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
De Boo et al
331
Figure 2. Procedure: (A) ascending aorta angiogram, (B) angiogram with guide catheter in the pseudoaneurysm, (C) control angiogram after positioning of the type II Amplatzer vascular plug (AVP) and prior to deployment, and (D) after deployment of the AVP.
treatment of choice. However, this procedure is associated with substantial morbidity and a mortality rate of circa 7%.2 Several less invasive endovascular approaches for closure of these pseudoaneurysms have been reported, especially in surgical high-risk patients.3-6 Our patient initially presented with an incidentally detected pseudoaneurysm of the ascending thoracic aorta, 25 years following aortic root repair and mAVR. At that time, coil embolization was performed with technically good result. However, during follow-up the aneurysm reopened and the patient was referred 8 years after the coil embolization for a possible second percutaneous closure. Preprocedural imaging showed that the pseudoaneurysm had reopened at its cranial portion. The neck was located at the dome of the pseudoaneurysm and its diameter was 6 to 8 mm on the various imaging modalities. Covering the neck with a stent graft was not considered possible for 2 reasons: first, there was an acute change in
diameter between the elongated, dilated aortic arch and the ascending aorta graft. Inadequate seal leading to a type I endoleak was assumed to be very likely. Second, the mechanical aortic valve prohibited a stable wire position for the stent graft delivery. The location of the neck and site of reopening increased the risk of coil migration during the procedure and therefore prohibited a second coil embolization. Several case reports have been published on the off-label use of atrial septal defect (ASD) and membranous ventricular septal defect (mVSD) occluders for ascending aortic pseudoaneurysm.6 These devices consist of 2 disks with a connecting waist that corresponds to the septal defect or neck diameter when used for percutaneous closure of pseudoaneurysms. An overall 86% (12 of 14) of technical success rate has been reported for these septal occluders.6 Depending on the size of the waist of the septal occluders, the disks are 4 to 8 mm larger in diameter. With the neck located at the
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
332
Vascular and Endovascular Surgery 48(4)
Figure 3. Postprocedural computed tomography (CT) angiogram (1 month) shows an unchanged, satisfactory position of the type II Amplatzer vascular plug with thrombosed ascending aortic pseudoaneurysm.
dome, we feared inadequate positioning with the use of either an ASD or a mVSD occluder. The type II AVP consists of 3 disks with a pin waist between both outer and the center disk. Positioning 2 disks in the pseudoaneurysm provided more stability and lowered the risk of device embolization that has been described in 2 patients where a septal occluder device was used.6 It should be noted however that both pseudoaneurysms treated were mycotic, whereas this was not the case in our patient. Consequently, we made the decision to use the type II AVP. Its successful use for the closure of an asymptomatic ascending aortic pseudoaneurysm has been described once before. This patient was treated 11 years after the initial cardiac surgery.7
Conclusions We present a successful endovascular closure of an ascending aortic pseudoaneurysm with the off-label use of a type II AVP. Although the long-term durability has not been established, this treatment is minimally invasive and can be considered as alternative to surgical correction, especially in high-risk patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thoracic Surg. 2000; 70(2):547-552. 2. Malvindi PG, van Putte BP, Heijmen RH, Schepens MAAM, Morshuis WJ. Reoperations for aortic false aneurysms after cardiac surgery. Ann Thorac Surg. 2010;90(5):1437-1443. 3. Zago AC, Saadi EK, Zago AJ. Endovascular approach to treat ascending aortic pseudoaneurysm in a patient with previous CABG and very high surgical risk. Catheter Cardiovasc Interv. 2011; 78(4):551-557. 4. Chapot R, Aymard A, Saint-Maurice JP, Bel A, Merland JJ, Houdart E. Coil embolization of an aortic arch false aneurysm. J Endovasc Ther. 2002;9(6):922-925. 5. Lin PH, Bush RL, Tong FC, Chaikof E, Martin LG, Lumsden AB. Intra-arterial thrombin injection of an ascending aortic pseudoaneurysm complicated by transient ischemic attack and rescued with systemic abciximab. J Vasc Surg. 2001;34(5): 939-942. 6. Noble S, Ibrahim R. Embolization of an Amplatzer mVSD occluder device used for percutaneous closure of an ascending aortic pseudoaneurysm: case report and literature review. Catheter Cardiovasc Interv. 2012;79(2):334-338. 7. Scholtz W, Jategankar S, Haas NA. Successful interventional treatment of a retrosternal pseudoaneurysm of the ascending aorta with an Amplatzer vascular plug type II. J Invasive Cardiol. 2010;22(3): E44-E46.
Downloaded from ves.sagepub.com at The University of Iowa Libraries on March 16, 2015
