Traumatic ascending aortopulmonary window following pulmonary artery stent dilatation: therapy with aortic endovascular stent graft

Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: case series and literature review

The number of vascular centers performing endovascular repair of ascending aortic disease is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies. However, approximately one quarter of patients are deemed unfit for open surgery. In this study, we describe three cases of ascending thoracic endovascular aortic repair (TEVAR) performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, and the third had a focal type A aortic dissection. In two cases, we used two abdominal aortic cuffs deployed from zone 0B to zone 0C, with no need for supra-aortic trunk debranching. In one case, we performed a "reverse" extrathoracic debranching, and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patient with an infected pseudoaneurysm, we performed ascending TEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak; however, clinical stabilization and infection control were obtained, and he was able to undergo heart surgery successfully. He underwent a second reintervention to treat superior mesenteric embolic occlusion. At 2 years of follow-up, all three patients were alive. Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially available endografts. However, no consensus has been reached regarding some critical aspects, such as the development of a standardized technique or the efficacy of the currently available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.

Interventions after Arterial Switch: A Single Low Case-Volume Center Experience

Background and Objectives: With the growing population of arterial switch operation survivors, the rate of late complications associated with the operation is growing as well. The aim of this publication is to share our experience and encourage collaboration between congenital cardiac surgeons and interventional cardiologists in treating late complications after arterial switch operation. Materials and Methods: A retrospective analysis of Vilnius University Santaros Clinics Cardiothoracic Surgery Centre arterial switch operation survivors who underwent additional treatment for late neo-pulmonary artery stenosis and aortic arch obstruction between 1989 and 2019 was conducted. Results: Out of 95 arterial switch operation survivors 14 (15%) underwent 36 reinterventions. The majority were treated for neo-pulmonary stenosis. The median time from arterial switch operation to the first reintervention was 1.4 years (interquartile range, 2 months to 2.4 years). 1, 3, 5, and 10 years intervention-free survival in patients treated for neo-pulmonary stenosis and aortic arch obstruction was 98, 94, 94, and 93% vs. 95, 94, 94, and 93%, respectively. There were no complications associated with redo surgical procedures, while eight patients who underwent catheter-based interventional treatment had treatment-related complications, including one death. Conclusions: Both neo-pulmonary stenosis and aortic arch obstruction (new aortic coarctations or aortic recoarctations) tend to develop in the first decade after an arterial switch operation. Surgical and catheter-based interventional treatment with good results is possible even in a small volume center. Close collaboration of the congenital heart team (congenital cardiac surgeons and interventional cardiologists) in choosing the best treatment option for an individual patient helps to minimize the risk of potential complications.

Pulmonary artery interventions after the arterial switch operation: Unique and significant risks

BACKGROUND

In the modern era, results of the arterial switch operation (ASO) for transposition of the great arteries are excellent. However, because of the LeCompte maneuver, there may be a propensity for development of pulmonary artery stenosis. We encountered atypical complications of pulmonary artery stenting in patients after the ASO, including aorto-pulmonary fistula and coronary compression.

METHODS

We performed a 10-year retrospective review of catheterizations performed in patients after ASO in our institution with a focus on adverse events.

RESULTS

Diagnostic and interventional catheterizations were performed in 47 patients. In 29 patients, 37 interventional procedures performed, which included pulmonary artery angioplasty and/or stenting. In this group, there were five major adverse events (14%), including three aorto-pulmonary fistulae and one coronary artery compression among patients having stent implantation or stent redilation. In addition, there were 6/37 (16%) intended stent procedures, which were aborted because there appeared to be high-risk of significant adverse events.

CONCLUSIONS

This review suggests that percutaneous intervention on pulmonary artery stenosis after ASO has high-risk and should be undertaken advisedly. Prior thorough evaluation of coronary arteries is mandatory as coronary reimplantation sites may be adjacent to sites of pulmonary artery stenosis. Furthermore, if pulmonary artery stent implantation or stent redilation is contemplated, the risk of stent fracture and possible AP fistula should be recognized. Primary use of reinforced covered stents should be considered.

Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

OBJECTIVES

To investigate the spectrum, etiology, and management of traumatic aortopulmonary (AP) communications after transcatheter interventions on the pulmonary circulation.

BACKGROUND

An iatrogenic AP communication is an unusual complication after balloon pulmonary artery (PA) angioplasty or stenting, or transcatheter pulmonary valve replacement (TPVR). However, with the increasing application of transcatheter therapies for postoperative PA stenosis and right ventricular outflow tract (RVOT) dysfunction, including percutaneous pulmonary valve replacement, consideration of the etiology, diagnosis, and management of this problem is important for interventional cardiologists performing such procedures.

METHODS AND RESULTS

We present three new cases, as well as gross anatomy and histopathology data, related to AP communications after PA interventions. We also review the literature relevant to this topic. Including these new cases, there have been 18 reported cases of iatrogenic AP communication after transcatheter interventions on the PAs or RVOT, primarily patients with transposition of the great arteries who underwent PA angioplasty after an arterial switch operation, or after TPVR in patients who had undergone a Ross procedure. The likely cause of such defects is PA trauma plus distortion of the neo-aortic anastomosis resulting from angioplasty or stenting of the RVOT or central PAs, with subsequent dissection through the extravascular connective tissue and into the closely adjacent vessel through the devitalized tissue at the anastomosis.

CONCLUSIONS

Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

An interesting case of an aortopulmonary artery fistula

Aortopulmonary artery fistulae are exceeding rare and may be associated with aortic arch aneurysms or thoracic aortic surgery. Here, we present a case of an aortopulmonary artery fistula in an 87-year-old woman with no history of aneursymal disease or thoracic surgery and discuss the likely aetiology and management of this condition.

Iatrogenic aortopulmonary fistula occurring after pulmonary artery balloon angioplasty: a word of caution

We describe the natural history of an adolescent patient who developed an aortopulmonary fistula (APF) after transcatheter stent placement for left pulmonary artery stenosis after neonatal repair of d-transposition of the great arteries. Due to its rarity, the APF was not initially diagnosed and treated until 4 months later. The APF was occluded with a covered stent. Because this is not an isolated report in the literature, we believe it should be considered as a potential complication in all patients after balloon dilation of stenotic pulmonary artery branches after arterial switch surgery.

Catheter Interventions for Pulmonary Artery Stenosis: Matching the Intervention with the Pathology

Pulmonary artery (PA) stenosis represents a heterogeneous defect with a wide morphology and etiology. Interventions to treat PA stenosis should be based on the location, severity, and cause of stenosis as well as the size of the patient at presentation. Specialized dilation balloons, stents, and delivery techniques have been developed to treat a variety of PA stenoses in small infants through adulthood. Early and intermediate results of angioplasty and stenting are superior to surgical results, while long-term data on angioplasty and stenting are becoming available for these proven safe and effective techniques.