Author + information
- Received February 20, 2008
- Revision received March 21, 2008
- Accepted April 3, 2008
- Published online June 1, 2008.
- Ravinay Bhindi, MBBS, PhD, FRACP, FESC⁎ (, )
- James Newton, MBChB, MRCP,
- Neil Wilson, MBBS, FRCP and
- Oliver J. Ormerod, DM, FRCP
- ↵⁎Reprint requests and correspondence:
Dr. Ravinay Bhindi, John Radcliffe Hospital, Department of Cardiology, John Radcliffe Hospital, Oxford, Oxfordshire OX3 9DU, United Kingdom.
A 76-year-old woman presented to hospital with a 1-month history of progressively worsening central chest pain. Her medical history was remarkable for a previous aortic valve replacement with an ascending aortic interposition graft 10 years earlier.
A computed tomography (CT) scan showed a large ascending aortic pseudoaneurysm with aortic communication through a defect at the superior aspect of the structure, below the level of the innominate vessels. Given the position of the pseudoaneurysm, the risk of repeat sternotomy was thought too high. Furthermore, the abdominal aorta was severely diseased and tortuous, making potential delivery of a covered stent difficult. It was therefore decided to attempt to close the mouth of the defect percutaneously.
Vascular access was achieved via the right brachial artery, and aortography demonstrated moderate dehiscence at the posterior aspect of the superior margin of the interposition graft (Fig. 1A, Online Video 1). Adjuvant intracardiac echocardiography (ICE) was performed with the imaging catheter in the superior vena cava and demonstrated a leak from the true aortic lumen into the false cavity (Fig. 1B). A 6-F Judkins right catheter was used with a 0.035-inch exchange length wire to enter the defect, and contrast injection through the catheter further defined the anatomy of the cavity (Fig. 1C). Balloon sizing was performed with a 10-mm Cristal balloon (Fig. 1C), and a 7-F Amplatzer Torqvue sheath was then used to deliver a 10-mm Amplatzer atrial septal defect device. This resulted in immediate reduction in flow into the defect by repeat aortography and ICE (Figs. 1D and 1E; Online Videos 2 and 3). A repeat CT scan 2 days later confirmed obliteration of the defect and thrombosis of the cavity (Fig. 1G).
Focal percutaneous sealing of ascending thoracic aneurysms has been successfully used previously by others (1); however, to our knowledge this is the first case to use the brachial access approach in the setting of previous aortic graft surgery with adjuvant ICE imaging. In cases where surgical correction is deemed too high-risk and stent coverage not feasible, such an approach can be considered.
For supplementary videos, please see the online version of this article.
- Received February 20, 2008.
- Revision received March 21, 2008.
- Accepted April 3, 2008.
- American College of Cardiology Foundation