Author + information
- Received January 24, 2017
- Accepted February 9, 2017
- Published online May 1, 2017.
- Davide Tavano, MD∗ (, )
- Marco Pocar, MD, PhD and
- Flavio Airoldi, MD
- Cardiovascular Department, IRCCS MultiMedica Hospital, Università degli Studi di Milano, Sesto San Giovani, Milan, Italy
- ↵∗Address for correspondence:
Dr. Davide Tavano, IRCCS MultiMedica, Via Milanese 300, 20099 Sesto San Giovanni, Milan, Italy.
An 87-year-old woman with symptomatic severe aortic stenosis was admitted to our institution for transcatheter aortic valve implantation. After an unsuccessful attempt of right internal jugular vein cannulation, the anesthesiologist observed a neck hematoma. The 7-F catheter was retrieved and the valve procedure aborted. Duplex scan was immediately performed and showed active arterial bleeding. Contrast-enhanced computed tomography documented a pseudoaneurysm originating from the subclavian artery at the level of the vertebral artery ostium (Figure 1). Catheterization was indicated for endovascular repair (1) and angiography confirmed the active bleeding from a laminar damage of the anterior subclavian arterial wall adjacent to the vertebral and internal thoracic artery ostia (Figure 2, Online Video 1). A mini-chimney technique (2) was chosen to preserve vertebral arterial flow and to prevent reverse flow from the vertebral artery with the potential for a type II residual endoleak. Two stents were deployed simultaneously: a 3.5 × 20-mm nonwoven, electrospun, polyurethane-covered coronary stent (Papyrus, Biotronik, Berlin, Germany) was implanted in the ostial vertebral artery through a 90-cm, 6-F femoral sheath, whereas a 10 × 59-mm balloon-expandable, polytetrafluoroethylene-covered stent (E-Ventus, Jotec, Hechingen, Germany) was implanted in the subclavian artery through a 12-cm, 7-F radial sheath. The proximal edges of both stents were aligned and slightly overlapped in the proximal subclavian artery (Figure 3). Control angiograms showed no residual bleeding and a patent vertebral artery (Figure 4, Online Video 2).
The chimney technique, most commonly adopted for endovascular aortic aneurysm repair, may also offer a straightforward solution to interrupt active hemorrhage, preserving the patency of noble arterial branches.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 24, 2017.
- Accepted February 9, 2017.
- 2017 American College of Cardiology Foundation