An aortic pseudoaneurysm (PSA) can occur

Transcription

1 Percutaneous Transcatheter Closure of a Large Pseudoaneurysm Arising From Anastomosis of a Surgical Graft With an Amplatzer Vascular Plug 4 Mark J. Russo, MD 1 ; Ross Milner, MD 2 ; Atman P. Shah, MD 2 From 1 Barnabas Heart Health Centers, Newark, New Jersey, and 2 University of Chicago Medicine, Chicago, Illinois. ABSTRACT: Open surgical repair remains the standard of care for treatment of pseudoaneurysms. However, given the significant risks of surgery, a limited number of recent case reports and small series describe percutaneous approaches to management of aortic pseudoaneurysms with stent-grafts, coils, and occluders. 1-4 We report a case of closure of an aortic pseudoaneurysm with a novel occluder, the Amplatzer Vascular Plug 4 (St. Jude Medical). VASCULAR DISEASE MANAGEMENT 2016;13(2):E53-E57 Key words: aneurysm repair, interventional cardiology, thoracic aortic aneurysm An aortic pseudoaneurysm (PSA) can occur after aneurysm or dissection repair, coronary artery bypass graft surgery, chest trauma, or aortic valve endocarditis. 5 Untreated PSAs carry a high mortality rate. 6 Open surgical repair remains the standard of care for treatment of PSAs; however, surgery is associated with significant morbidity and mortality. An alternative to open surgical repair, a percutaneous approach to management of aortic PSA, has been previously reported with stentgrafting, coils, and occluders. 7 We report a case of closure of an aortic PSA with a novel, fourth generation, occluder, the Amplatzer Vascular Plug 4 (St. Jude Medical). CASE PRESENTATION A 57-year-old male presented to his nearest hospital with acute onset of chest pain. His past medical history was significant for a type A aortic dissection repair with a 24 mm Dacron Hemashield graft (Maquet) 2 years prior and subsequent sternal wound infection requiring debridement. Afterward, he developed restrictive physiology and underwent a pericardial stripping via thoracotomy. Computed tomography (CT) scan revealed a large PSA (Figure 1) with a discrete and narrow entry point arising from the ascending aorta near the previous suture line that was confirmed by transesophageal echocardiography (Figure 2). The patient was transferred to our institution for further management. In light of his complex surgical history, a percutaneous transcatheter approach was chosen. TECHNIQUE The procedure was performed in the cardiac catheterization laboratory with the patient under conscious sedation. A 6 Fr sheath was placed in the right common femoral artery. Aortic arch angiography was performed with a 6 Fr pigtail catheter and selective angiography Vascular Disease Management February

2 Figure 1. Computed tomography of the chest revealing a large pseudoaneurysm (coronal and sagittal views, red arrows). Figure 2. Transesophageal echocardiography with color Doppler flows into the pseudoaneurysm (white arrow). confirmed a large ascending aortic PSA (Figure 3). The patient was given 7,500 units of intravenous Figure 3. Selective angiography of the aortic pseudoaneurysm (red arrow). heparin and a 5 Fr SIM-1 catheter (Cook Medical) was advanced over a standard.035 x 260 cm guidewire into the ascending aorta. The catheter was used to selectively cannulate the ostium of the PSA (Figure 3). A.035 x 260 cm straight soft Glidewire (Terumo Medical) was advanced into the PSA (Figure 4). The SIM-1 catheter was exchanged out for a 0.44 x 130 mm DAC catheter (Concentric Medical), which was Vascular Disease Management February

3 Figure 4. Deployment of the glidewire in the pseudoaneurysm (red arrow). Figure 6. Aortogram and demonstrating occlusion of the pseudoaneurysm (red arrow). through the DAC catheter and half of the device was exposed in the PSA. The device was pulled back so that the second dome was exposed on the aortic side (Figure 5). Aortography was performed to demonstrate occlusion and the device was assessed for stability. Once stability and closure were confirmed, the device was released. Repeat aortography revealed no residual leak (Figure 6). There were no complications of the procedure and the patient did well post-procedure. This patient received standard post aortic dissection follow-up with CT angiogram at discharge, CT angiogram 1 month after discharge, and then subsequent yearly CT angiograms. No subsequent bloodwork was performed. Figure 5. Deployment of the Amplatzer Vascular Plug 4 (St. Jude Medical) in the pseudoaneurysm (red circle). advanced over the wire into the PSA. The glidewire was removed and a 6 mm Amplatzer Vascular Plug 4 (VP4; St. Jude Medical) was advanced DISCUSSION The etiologies of ascending aortic PSA are numerous and include surgery, trauma, infection, and autoimmune and inflammatory origin. 5,8-10 Possible mechanisms for postsurgical pseudoaneurysm formation include graft infection, dissected native aorta, and tissue Vascular Disease Management February

4 necrosis after excessive use of biologic glue. 8 Positive blood cultures can confirm an infectious origin, and were found in 3 out of 10 patients in a case series of 10 patients who were reoperated after postsurgical false aneurysm. 8 However, up to 25% of cases of aortitis may present with normal blood cultures. 10 Blood cultures were performed on this patient and the results were negative. There were also no signs of infection (no fever, tachycardia, or leukocytosis). This patient was treated preoperatively with vancomycin and piperacillin-tazobactam, because any delay in treatment, even in the absence of positive blood cultures, would have been catastrophic. While antibiotics are important, even in the face of negative cultures, surgical intervention is imperative. If left surgically untreated, a PSA may result of the delivery system, allowing use of the device in in rupture, thromboembolism, and fistula formation. 11 The long-term prognosis of these repairs is unknown, The VP4 is a self-expanding nitinol mesh occlusion device attached to a 155 cm delivery cable. The VP4 has high technical success rates, and the ability to recapture and reposition gives the device an advantage over coils or stents. 13 The device can also be deployed without using a guide catheter, giving it additional clinical reach. As such, it has been used for splenic artery embolism, 14 internal carotid artery occlusions for tumor treatment, 15 and the treatment of congenital heart defects. 16 Its low-profile design not only confers deliverability via a 4 Fr or 5 Fr diagnostic catheter but also, given the smaller surface area, decreases the risk of erosion. The added advantage of the VP4 over previous generations of the device is the decrease in size much smaller vessels. 13 Here we present a case of aortic PSA repair with an but similar case reports describe no complications in Amplatazer VP4 that, to the best of our knowledge, the first year. 12 has not been previously reported in the literature. In While surgical repair is the first-line treatment, this our experience, this novel device is a safe endovascular alternative to treat postsurgical aortic PSA in pa- patient had undergone prior repair of type A dissection with sternal flaps and pericardial stripping. Therefore, tients who meet the following criteria: (1) no active the risks of performing a reoperation were significant. infection; (2) adequate access via the femoral vessels; Prior reports have described closure of PSA with septal occluders, vascular plugs, endovascular stents, or consideration of the feasibility of device deployment; (3) encouraging analysis of the access site with special coils. Closure with septal occluders or prior versions of and (4) presence of an enlarged aorta in which aortic vascular plugs require at least a 6 Fr delivery catheter, endograft deployment is not feasible. Because of the which may be difficult to advance to the neck of the novelty of the device, its use should be considered on pseudoaneurysm. Furthermore, septal occluders and a case-by-case basis. Patients who have already undergone a previous thoracic surgery are at increased risk other plugs may have larger surface areas whose longterm effects, such as vascular erosion, are unknown. of morbidity and mortality with a repeat surgical intervention. As the use of the Amplatzer VP4 is expanded After eliminating surgical intervention due to prohibitive risks, we opted for endovascular repair with the and vascular specialists gain experience with the device Amplatzer VP4 occlusion device. in this setting, the device may prove particularly useful Vascular Disease Management February

5 for the treatment of aortic pseudoaneurysm, even as a first-line treatment option over open surgery. n Editor s note: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content herein. Manuscript received July 1, 2014; provisional acceptance given September 30, 2014; manuscript accepted November 9, Address for correspondence: Mark J. Russo, MD, MS, Barnabas Heart Health Centers Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Suite G5, Newark, NJ 07112, United States. mr2143@gmail.com. REFERENCES 1. Zicho D, Cartwright N, Bizzarri F, et al. Endovascular stent graft repair of suture-line pseudoaneurysm following ascending aorta replacement. Vasc Endovascular Surg. 2014;48(3): Gray BH, Langan EM 3rd, Manos G, Bair L, Lysak SZ. Technical strategy for the endovascular management of ascending aortic pseudoaneurysm. Ann Vasc Surg. 2012;26(5): Joyce DL, Singh SK, Mallidi HR, Dake MD. Endovascular management of pseudoaneurysm formation in the ascending aorta following lung transplantation. J Endovasc Ther. 2012;19(1): Eldien AS, Deo S, Oluseun AO, Rihal CS, Joyce L. Endovascular approach to treat aortic pseudoaneurysms: could it be a safe alternative? Heart Surg Forum. 2012;15(1):E34-E Razzouk A, Gundry S, Wang N, et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg. 1993;59(12): Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32(3): Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv. 2012;80(4): Katsumata T, Moorjani N, Vaccari G, Westaby S. Mediastinal false aneurysm after thoracic aortic surgery. Ann Thorac Surg. 2000;70(2): Sabri MN, Henry D, Wechsler AS, DiSciascio G, Vetrovec GW. Late complications involving the ascending aorta after cardiac surgery: recognition and management. Am Heart J. 1991;121(6 Pt 1): Cevasco M, Menard MT, Bafford R, McNamee CJ. Acute infectious pseudoaneurysm of the descending thoracic aorta and review of infectious aortitis. Vasc Endovascular Surg. 2010;44(8): Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-case series of six patients. Catheter Cardiovasc Interv. 2009;73(4): Kleisli T, Wheatley GH 3rd. Closure of a penetrating ulcer of the descending aorta using an Amplatzer occluder. Ann Thorac Surg. 2009;88(3):e18-e Mordasini P, Szucs-Farkas Z, Do DD, Gralla J, Kettenbach J, Hoppe H. Use of a latest-generation vascular plug for peripheral vascular embolization with use of a diagnostic catheter: preliminary clinical experience. J Vasc Interv Radiol. 2010;21(8): Ng EH, Comin J, David E, Pugash R, Annamalai G. AMPLATZER Vascular Plug 4 for proximal splenic artery embolization in blunt trauma. J Vasc Interv Radiol. 2012;23(7): Macht S, Mathys C, Schipper J, Turowski B. Initial experiences with the Amplatzer Vascular Plug 4 for permanent occlusion of the internal carotid artery in the skull base in patients with head and neck tumors. Neuroradiology. 2012;54(1): MacDonald ST, Carminati M, Butera G. Initial experience with the Amplatzer Vascular Plug IV in congenital heart disease: coronary artery fistula and aortopulmonary collateral artery embolization. J Invasive Cardiol. 2011;23(3): Vascular Disease Management February