Author + information
- Received February 7, 2018
- Accepted February 13, 2018
- Published online May 21, 2018.
- Luca Bertoglio, MDa,
- Tommaso Cambiaghi, MDa,∗ (, )
- Federico Pappalardo, MDb,
- Michele De Bonis, MDc,
- Alessandro Castiglioni, MDc and
- Roberto Chiesa, MDa
- aDivision of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
- bDivision of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy
- cDivision of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
- ↵∗Address for correspondence:
Dr. Tommaso Cambiaghi, Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milano, Italy.
A 64-year-old woman underwent uneventful implantation of a HeartWare left ventricular assist device (HeartWare, Framingham, Massachusetts) as bridge to transplant, but presented at 3 years follow-up with computed tomography (CT) angiographic evidence of fissuration of the outflow conduit (Figure 1).
The most likely causative factor of this complication was the erosion of the conduit graft on the edge of a ruptured steel sternal stitch (not evident at index procedure, but visible at follow-up CT).
In order to prevent complete rupture of the graft pseudoaneurysm and to avoid serious iatrogenic lesions at re-sternotomy, we decided to manage the fissuration with a percutaneous endovascular approach.
A stiff Lunderquist guidewire (Cook Medical, Bloomington, Indiana) was exchanged inside the outflow graft via a right brachial access and a 12 × 80-mm Fluency covered stent (Bard Peripheral Vascular, Tempe, Arizona) was deployed across the fissuration to exclude the pseudoaneurysm (Figure 1). Left ventricular assist device (LVAD) speed reduction to 2,200 rpm was necessary to improve accuracy in deployment and decrease afterload during post-dilation with a 10 × 80-mm Armada-35 balloon (Abbott Vascular. Santa Clara, California). Completion angiography and CT angiography showed completed exclusion of the fissuration and patency of the outflow conduit. The procedure was uneventful, and the patient was discharged in good clinical status 4 days later on oral anticoagulation therapy.
Interestingly, 10 days later, the patient required explantation of the LVAD due to outflow thrombosis, involving the proximal portion of the graft while sparing the covered stent. The re-sternotomy was achieved without major bleeding as the fissuration was successfully occluded by the wall of the stent.
Although VAD complications have been extensively reported (1), only 1 case of minor graft erosion secondary to a defective device is present in the published reports and required redo sternotomy and device replacement (2).
To our knowledge, this is the first total endovascular management of an outflow conduit fissuration, which might eliminate the need of open cardiac surgery.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 7, 2018.
- Accepted February 13, 2018.
- 2018 American College of Cardiology Foundation