Author + information
- Received August 14, 2014
- Revision received August 31, 2014
- Accepted September 10, 2014
- Published online March 1, 2015.
- Manolis Vavuranakis, MD, PhD∗ (, )
- Konstantinos Kalogeras, MD (, )
- Carmen Moldovan, MD,
- Sophia Vaina, MD, PhD,
- Dimitrios Vrachatis, MD,
- Maria Kariori, MD,
- Evelina Mpei, MD,
- Dimitrios Tousoulis, MD, PhD and
- Christodoulos Stefanadis, MD, PhD
- ↵∗Reprint requests and correspondence:
Dr. Manolis Vavuranakis, National & Kapodistrian University of Athens, 1st Department of Cardiology, Hippokration Hospital, 13 Astypaleas, Anoixi, Attiki 14569, Greece.
A 63-year old man presented with chest pain. He had undergone coronary artery bypass graft surgery 15 years earlier and mitral valve repair due to severe regurgitation 6 months earlier with a simultaneous right internal mammary artery (RIMA) to left anterior descending artery graft. The early postoperative period was complicated by mediastinitis, which required surgical drainage. Due to persistent infection, a vacuum device was used to drain inflammatory fluid.
During the present admission, the patient was afebrile with mild right arm edema, right jugular vein distention, and audible systolic murmur. A computed tomography (CT) scan exposed a large aortic pseudoaneurysm with communication 1 cm below the innominate artery, probably as a result of inflammation, cannulation, and vacuum tubing (Figures 1A and 1B, Online Video 1).
Because of the 2 sternotomies, the RIMA graft across the sternum, and the position of the pseudoaneurysm, surgical treatment was not considered by the heart team. Thus, percutaneous closure of the pseudoaneurysm mouth with an Amplatzer septal occluder was selected.
However, there were concerns regarding the stability of the surrounding the orifice aortic rims and the support they could provide. Defect sizing was based on multisliced CT angiography, which showed the orifice to be 10 mm.
Via femoral access, a 0.035′-guidewire was inserted into the pseudoaneurysm, and over that, a 5-French multipurpose catheter was advanced into its cavity (Figure 2A, Online Video 2). The procedure was guided by angiography and transthoracic echocardiography (TTE). Finally, a 12-mm Amplatzer atrial septal defect device was successfully delivered (Figure 2B, Online Video 3). This resulted in immediate flow elimination confirmed by Doppler (Figure 2C, Online Video 4). A repeat CT scan 10 days later confirmed a pseudoaneurysm size reduction by thrombus development in the cavity (Figures 3A and 3B).
In our case, the pseudoaneurysm cavity had relatively post-inflammatory fragile rims and large dimensions, which resulted in adjacent great vessel compression. Device implantation was even more challenging without TEE guidance due to the high orifice location. In conclusion, large post-inflammatory pseudoaneurysms can be successfully closed with off-label use of available equipment (1,2). However, the development of specific devices for on-label use is required.
For supplemental material and videos, please see the online version of this article.
Dr. Vavuranakis is a proctor for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 14, 2014.
- Revision received August 31, 2014.
- Accepted September 10, 2014.
- 2015 American College of Cardiology Foundation