Author + information
- Received May 19, 2019
- Accepted June 4, 2019
- Published online September 16, 2019.
- Virginia Pascual-Tejerina, MDa,
- Ángel Sánchez-Recalde, MD, PhDb,∗ (, )
- Federico Gutiérrez-Larraya, MD, PhDc and
- José L. Zamorano, MD, PhDb
- aDepartment of Cardiology, La Paz University Hospital, Madrid, Spain
- bDepartment of Cardiology, Ramón y Cajal University Hospital, Madrid, Spain
- cDepartment of Pediatric Cardiology, La Paz University Hospital, Madrid, Spain
- ↵∗Address for correspondence:
Dr. Angel Sanchez-Recalde, Department of Cardiology, Ramón y Cajal University Hospital, Carretera Colmenar Viejo Km 9.100, 28034 Madrid, Spain.
A 49-year-old woman underwent Dacron patch aortoplasty for coarctation of the aorta (CoAo) at 5 years of age. She was under antihypertensive treatment and had a 20-mm Hg right arm-leg gradient in the last clinical visit. Electrocardiogram was normal and transthoracic echocardiography showed a bicuspid aortic valve with a subaortic membrane without hemodynamically significant stenosis. Cardiac magnetic resonance (CMR) revealed a 45-mm aortic pseudoaneurysm in the descending aorta, which included the origin of the left subclavian artery (LSA), and a moderate CoAo just distal to the pseudoaneurysm (Figure 1A). Cardiac catheterization demonstrated a peak-to-peak transcoarctation gradient of 20 mm Hg and the aortogram revealed the same anatomy as CMR showed (Figure 1B, Online Video 1).
Right femoral, left femoral, and left radial arteries were cannulated. A noncovered pre-mounted CP stent measuring 22 mm in diameter and 110-mm long (NuMED, Hopkinton, New York) was successfully deployed at the CoAo through a 14-F Mullins sheath (Cook, Bloomington, Indiana) via the right femoral artery (Figure 1C). Afterward, a 9-mm diameter and 27-mm-long covered BeGraft stent (Bentley, Hechingen, Germany) was implanted at the ostium of the LSA passing through the struts of the CP stent over an arterioarterial guidewire loop between the radial and left femoral arteries (Figure 1D), redirecting the flow from the descending aorta to the LSA excluding the pseudoaneurysm (Figure 1E). Then, superselective catheterization of the pseudoaneurysm with an internal mammary artery 6-F guiding catheter and subsequent embolization with coils were performed successfully. There was no transcoarctation gradient post–stent implantation and the pseudoaneurysm was completely excluded (Figures 1F and 1G, Online Videos 2 and 3). The patient went on to make an uneventful recovery and was discharged home. At 3-month follow-up, aortic pseudoaneurysm was completely thrombosed in the control CMR (Figure 1H).
The conventional treatment consists of a hybrid approach with occlusion of the aortic pseudoaneurysm and LSA ostium using a stent graft, left carotid-axillary bypass grafting, and a surgical clipping of the LSA proximal to the pseudoaneurysm. The classic percutaneous approach is to seal the pseudoaneurysm with a covered stent graft, recross it with a guidewire from the LSA, and implant another covered stent at the ostium of this artery. As the origin of the LSA was inside the pseudoaneurysm in this particular case, recrossing the covered stent from the LSA could have been particularly difficult or impossible. To avoid this situation, we describe a simple and appealing alternative technique.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 19, 2019.
- Accepted June 4, 2019.
- 2019 American College of Cardiology Foundation