Author + information
- Hassan Baydoun,
- Henry Quevedo,
- Gholam Ali and
- Alvaro Alonso
Ascending Aortic Pseudoaneurysms (AAPs) are a rare but life-threatening complication of AA surgeries. Open repairs using surgical grafts are the current standards of care. Endovascular therapies remain less studied options for high-risk patients. We present a case of percutaneous coiling of AAP.
A 61 year-old female was admitted for chest pain with a prior history of surgical AAP repair following an AA surgical graft for a Type A dissection. A CT angiography of the chest showed a 6x4cm AAP arising from the proximal portion of the previous graft. The AAP neck was estimated at 7mm, arising 20 degrees from the anterior/oblique lower end of the previous graft. Due to her multiple cardiac surgeries and comorbidities, she was not a candidate for CT surgery. Instead, an endovascular approach was selected for treatment. Initially, an attempt was made using an Amplatzer cribiform occluder. However, due to the short AP diameter, adequate wire needed to advance the delivery sheath was unsuccessful. A percutaneous coiling procedure was instead performed. After getting bilateral common femoral accesses, a 6 Fr IMA guide catheter was used to engage the AAP. A 4 Fr Glidecath with 0.014” wire was advanced into the IMA guide wire to access the AAP. Thirty-five 0.035in Azur Framing Coils and Azur with Hydrogel Coils ranging from 20x50mm to 6x20mm were then introduced into AAP. The patient tolerated the procedure without complications. A three-month follow up CT scan showed a thrombosed AAP with minimal residual shunt.
Retrospective studies report high mortality for open surgical repairs for AAP. Endovascular approaches are however limited to case reports as they are offered to high-risk patients. Septal occluders and stent grafts were used successfully in previous studies with similar in-hospital mortality rates compared to open repairs. In the case of septal occluders, narrow neck aneurysms posed a challenge for delivery of the occluder, a problem we also encountered. Similarly, the current stenting material was primarily designed for the abdominal aorta and the tortuous nature of the AA and its proximity to the aortic valve and coronaries make it difficult to translate this technique. Coiling has been used primarily as an adjuvant to other endovascular techniques but only a handful of case reports have been published reporting its stand-alone use.
Patients who are at high risk for surgical repair of AAP have several available endovascular options for treatment depending on the size and characteristics of the AAP.