Abstract

An aortic pseudoaneurysm is a rare, but serious condition which can result in life-threatening complications. It is usually caused by previous cardiac surgery, trauma, or infection. Due to the high likelihood of rupture with primary surgical intervention, endovascular closure may be performed as the standard of care in eligible cases. In this article, we present a case of a huge aortic pseudoaneurysm with a wide neck which could safely be closed using an atrial septal occluder.

Although aortic pseudoaneurysm (APA) is a rare pathology, it can be fatal up to 61% if left untreated.[1] Aortic clamp site, cannulation site, aortotomy suture line, aortic needle vent areas or vein graft anastomosis itself can accelerate the natural process and increase the probability of developing APA in the early or late period, particularly in patients with atherosclerotic aortic wall and degenerative aorta with ulcerated plaque.[2] Although surgery is still the most common treatment option, the mortality rate varies between 7 and 41%.[3] R ecently p ercutaneous A PA r epair using an atrial septal defect (ASD) closure device can be preferred over surgery to avoid high risks and reduce mortality.[3] I n t his a rticle, w e r eport o ne o f the limited cases in the literature in which APA was closed successfully using an ASD closure device in an unusual position.

Case Presentation

A 58-year-old male patient was admitted with a history of hypertension and peripheral arterial disease who underwent three-vessel coronary artery bypass grafting (CABG) seven months previously (left internal mammary artery [LIMA]-to-left anterior descending artery [LAD], saphenous vein graft [SVG]-to-first obtuse marginal branch [OM1], and SVG to right coronary artery [RCA]). The patient presented with complaints of chest pain and a local pulsatile swelling on the left anterior chest wall.

Due to the pulsatile swelling on the left anterior chest wall, computed tomography angiography (CTA) imaging was performed immediately. It revealed that the pseudoaneurysm, measuring 77.8?62.9?58.6 mm, was located at the ascending aorta, corresponding to the aortic cannulation site ( Figure 1a, 2c). The distance between the neck of the pseudoaneurysm and vital structures such as brachiocephalic artery, proximal anastomoses of the RCA and OM1 was safe for ASD closure device on CTA. Transthoracic echocardiography (TTE) showed an APA with an ellipsoid-shaped neck measuring 25.8?37 mm, filling with contrast material during each cardiac cycle and located between the ascending aorta and the pseudoaneurysm sac ( Figure 1b). Systolic left ventricle functions were normal (left ventricle ejection fraction: 60%). The structure of aortic valve was determined normal and there was mild mitral regurgitation. Coronary angiography revealed that SVG to RCA and LIMA graft were patent, and SVG to CxOM1 was occluded. After the patient was evaluated by the Heart Team, the surgical procedure was deemed high risk and it was decided to perform the intervention using an ASD closure device.

Figure 1: (a) Computed tomography angiography axial section and (b) transthoracic echocardiography showing a large pseudoaneurysm sac (red arrows and ? sign) attached to the ascending aorta (? sign) with a wide neck (? sign) and causing a pulsatile mass (blue arrows) in the adjacent subcutaneous tissue. (c) Fluoroscopic image of the successful deployment of the ASD closure device. White arrows show the left disc of ASD closure device; yellow arrows show the right disc of ASD closure device. ASD: Atrial septal defect.

The procedure was performed under the guidance of conventional angiography and TTE. A pigtail catheter was placed over a 0.035-inch guidewire into the ascending aorta through right radial artery access. Judkins right diagnostic catheter and the super stiff guidewire were placed over a 0.035-inch guidewire into the pseudoaneurysm sac through right femoral artery access. The delivery system was, then, placed to the aneurysm sac under the guidance of fluoroscopy and TTE. Since the APA neck had an ellipsoidal shape and its long axis diameter was 37 mm, the left disc of the 39-mm Occlutech Figulla® F lex I I A SD c losure d evice (OFF II, Occlutech International AB, Helsingborg, Sweden) was positioned inside the pseudoaneurysm sac and the right disc was positioned in the ascending aorta without any complications ( Figure 1c). At the end of the procedure, the flow in the sac decreased and there was stagnation in the contrast staining sac. The TTE repeated in the days following the procedure showed that the flow toward the pseudoaneurysm decreased progressively, and the sac of the pseudoaneurysm was seen to be completely thrombosed at the end of the first postoperative week. After the patient's hemodynamic status stabilized, he was discharged with antiplatelet therapy. No complications developed during follow-up and his complaints were completely resolved. During follow-up one month after the procedure, TTE confirmed no flow into the sac of the pseudoaneurysm and CT scan showed that the sac of the pseudoaneurysm is completely trombosed ( Figure 2a, 2b, 2d). Written informed consent was obtained from the patient.

Figure 2: Computed tomography angiography (a) axial and (b) sagittal section after the procedure. Three-dimensional CTA reconstruction (c) before the procedure and (d) after the procedure. ? sign: a large pseudoaneurysm sac; ? sign: the neck of the pseudoaneurysm; ? sign: ascending aorta; red arrows: thrombosed pseudoaneurysm; yellow arrows: the right disc of ASD closure device; blue arrows: the left disc of ASD closure device; white arrows: saphenous vein graft -right coronary artery. CTA: Computed tomography angiography; ASD: Atrial septal defect.

Discussion

An APA is typically a life-threatening complication which develops after cardiac surgery.[3, 4] Although classical open surgical repair of APA is the standard treatment, it is technically difficult, has many post-procedural complications, and carries a high risk of mortality.[3] T he l ack o f a dequate and reliable comparison of preoperative patient characteristics limits direct comparison of surgical and percutaneous outcomes.[5] A lthough a l imited number of studies have been reported due to the high surgical risk associated with the use of an ASD closure device in APA repair, the results obtained, including our case, are promising.[3] Closure of APA using an ASD closure device was first reported by Bashir et al.[6] Subsequently, several cases of APA successfully repaired using an ASD closure device were reported.[1] However, fatal complications such as inappropriate and inadequate positioning of leakage around the device, and conversion to open surgery have also been reported.[1, 3] Therefore, it is of utmost importance to develop a detailed preoperative preparation and strategy with the cardiac team to achieve a successful repair procedure and avoid post-procedure complications.

The size, shape and neck of the pseudoaneurysm sac and the possible interaction of the device to be used with adjacent anatomical structures are the technical determinants for the success of the procedure. The ASD closure device should be large enough to completely cover the neck of the pseudoaneurysm and should not damage adjacent anatomical structures, when the device is precisely positioned. Therefore, the distance of the pseudoaneurysm to the coronary ostia, aortic leaflets and aortic arch elements is of paramount importance.[7] Various imaging tools such as CTA imaging, TTE and/or transesophageal echocardiography, and cardiac magnetic resonance imaging can be used to accurately evaluate all of these structures.[4] In patients with a very high risk of rupture, as in our case, percutaneous closure of the pseudoaneurysm, reducing intra-sac pressure and allowing it to thrombose gradually within a week may eliminate the risk of early rupture. However, approximately 20% of these percutaneous closures may cause sac enlargement due to slight leakage into the sac and migration due to malposition of the device. Migration and embolization of the device may occur even after one year of follow-up after the procedure.[1] A lthough t he t iming of follow-up C TA scans in the management of APA is not standardized, it is clear that these patients require a certain level of surveillance. Based on this finding, we would continue to follow our case with CTA imaging for long-term results.

In conclusion, in appropriate cases of aortic pseudoaneurysms where surgical repair poses a high risk, percutaneous repair using an atrial septal defect closure device can be considered as a treatment option which can prevent the high risk. However, for the safety and effectiveness of this technique, analysis of data on similar case reports from more than one center regarding percutaneous closure is needed.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: All authors contributed equally to the article.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

References

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