Comment
Our case illustrates the novel use of TEVAR to prevent the catastrophic
and real potential for embolic stroke on challenging re-entry for aortic
PSA repair. This is a rare entity, and previous cardiac surgery is the
most common cause of ascending PSA. While endovascular repair has
successfully been applied as primary therapy, anastomotic constraints as
well as common co-existence of infection may preclude it, requiring open
repair. We recognize from prior experience that clots migrating from the
PSA into the aorta during the circulatory arrest and sternal opening
represent a high embolic risk. To mitigate this risk, we introduced a
novel hybrid approach, in which TEVAR was used to prevent embolism of
the large volume of hematoma within the pseudoaneurysm. The TEVAR graft
accomplished 2 goals: prevention of embolic stroke and maintenance of
selective antegrade cerebral perfusion during circulatory arrest.
Although this case represents a unique clinical scenario, requiring an
innovative solution, we believe that the interplay between endovascular
and open surgical techniques showcased here serves as an excellent
example of the potential strategies that could develop and progress the
state of the art in aortic surgery and underscores the need for
cardiothoracic surgeons to develop a familiarity and skillset with
endovascular techniques moving into the future.
References
- 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; 73:521–529.
- Kanani RS, Neilan TG, Palacios IF, Garasic JM. Novel use of the
Amplatzer septal occluder device in the percutaneous closure of
ascending aortic pseudoaneurysms: a case series.Catheter Cardiovasc
Interv. 2007; 69:146–153.
- Lyen SM, Rodrigues JC, Manghat NE, Hamilton MC, Turner M. Endovascular
closure of thoracic aortic pseudoaneurysms: a combined device
occlusion and coil embolization technique in patients unsuitable for
surgery or stenting.Catheter Cardiovasc Interv. 2016; 88:1155–1169.
- Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS.
Percutaneous therapeutic approaches to closure of cardiac
pseudoaneurysms.Catheter Cardiovasc Interv. 2012; 80:687–699.
- F.A. Atik, J.L. Navia, L.G. Svensson, et al. Surgical treatment of
pseudoaneurysm of the thoracic aorta. J Thorac Cardiovasc Surg, 132
(2006), pp. 379-385
Figure 1. Preoperative CT angiogram demonstrating a bilobed
pseudoaneurysm arising from the ascending aorta, just proximal to the
aortic arch takeoff measuring 3.6 x 2.8 cm with a large peri-aortic and
mediastinal hematoma.
Figure 2. Fluoroscopic image of the TEVAR graft positioned in the
proximal aorta
Figure 3. Fluoroscopic image taken after deployment of the TEVAR graft
into the ascending aorta.