Endovascular Stent-Graft Repair of Late Pseudoaneurysms After Surgery for Aortic Coarctation

Necessity of life-long follow-up after surgery for coarctation of the aorta: a case series of very late false aneurysm formation

BACKGROUND

Coarctation of the aorta accounts for 5-7% of congenital defects of the heart and great vessels. It requires treatment in the form of open surgical or percutaneous repair. Common long-term complications include re-stenosis and aneurysm formation. The formation of a false aneurysm is a complication with a significant morbidity and mortality.

CASE SUMMARY

We reviewed six cases of late false aneurysm after repair of a coarctation of the aorta. Our six cases developed a false aneurysm after an open surgical repair of a coarctation more than 30 years after initial surgical repair. All aneurysms were located at the aortic repair site.

DISCUSSION

The symptoms or risk factors in the described cases are not uniform and are difficult to include in a general follow-up protocol. Guidelines recommend frequent evaluation, but do not specify duration or intervals of imaging follow-up. Our cases support the necessity of life-long follow-up in patients with open aortic repairs irrespective of symptomatology.

Transcatheter Treatment of "Complex" Aortic Coarctation Guided by Printed 3D Model

The transcatheter approach is nowadays considered a cost-effective alternative to surgery in adults with "complex" aortic coarctation. The printed 3D model was crucial in planning transcatheter treatment of a complex case of postsurgical aortic re-coarctation, due to coexistence of transverse aortic arch stenosis and pseudoaneurysm as well as aneurysm of the descending aorta. (Level of Difficulty: Advanced.).

Endovascular repair of aortic coarctation pseudoaneurysm using an off-label "hourglass" stent-graft configuration

PURPOSE

To describe an endovascular technique for treating a pseudoaneurysm of the thoracic aorta using an off-label "hourglass" stent-graft configuration.

CASE REPORT

A 68-year-old patient with prior open thoracic aorta coarctation repair presented with recurrent coarctation and concurrent enlarging 6-cm bilobed pseudoaneurysm involving the previous anastomosis. There was significant discrepancy in the aortic diameter (measured from wall to wall) proximal to the coarctation (14 mm), at the narrowest segment (8 mm), and distally (23 mm). Endovascular repair included deployment of an inverted iliac limb proximally, followed by an inverted aortic converter distally, giving an "hourglass" configuration. There were no perioperative or stent-graft-related complications at 5-year follow-up. The aneurysm regressed from 61 to 25 mm.

CONCLUSION

The use of inverted stent-grafts can allow tapering and flaring to adapt to discrepant aortic diameters. This technique may be useful in select patients with prior coarctation repair who do not need excessive dilation of the narrow aortic segment.

Transcatheter intervention for complex ascending aortic pseudoaneurysm after cardiac surgery

BACKGROUND

Ascending aortic pseudoaneurysm (PsA) is an uncommon but surgically challenging problem with high morbidity and mortality. Herein we describe the efficacy and safety of the different approaches to transcatheter intervention for repair of ascending PsA and assess the selection of occluder devices using real-time 3-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE).METHODS AND RESULTS: Three patients with complex ascending PsA after cardiac or aortic root surgery were treated with transcatheter intervention due to high risk for redo surgery. Perioperative RT 3D-TEE combined with fluoroscopy was used for monitoring. All ascending PsA were successfully occluded with different devices using the transcatheter technique either with the transapical, transarterial approach, or transvenous combined with hybrid process depending on lesion anatomy.

CONCLUSIONS

Treatment of complex ascending PsA with transcatheter or combined hybrid intervention with cautious planning based on patient presentation and well-coordinated teamwork was successful. RT 3D color Doppler TEE provided precise information for the selection of appropriate occluder device, and also facilitated the procedure by guiding the catheter through difficult anatomy.

Endovascular treatment of late thoracic aortic aneurysms after surgical repair of congenital aortic coarctation in childhood

Background

In some patients, local surgery-related complications are diagnosed many years after surgery for aortic coarctation. The purposes of this study were: (1) to systematically evaluate asymptomatic adults after Dacron patch repair in childhood, (2) to estimate the formation rate of secondary thoracic aortic aneurysms (TAAs) and (3) to assess outcomes after intravascular treatment for TAAs.

Methods

This study involved 37 asymptomatic patients (26 female and 11 male) who underwent surgical repair of aortic coarctation in the childhood. After they had reached adolescence, patients with secondary TAAs were referred to endovascular repair.

Results

Follow-up studies revealed TAA in seven cases (19%) (including six with the gothic type of the aortic arch) and mild recoarctation in other six (16%). Six of the TAA patients were treated with stentgrafts, but one refused to undergo an endovascular procedure. In three cases, stengrafts covered the left subclavian artery (LSA), in another the graft was implanted distally to the LSA. In two individuals, elective hybrid procedures were performed with surgical bypass to the supraaortic arteries followed by stengraft implantation. All subjects survived the secondary procedures. One patient developed type Ia endoleak after stentgraft implantation that was eventually treated with a debranching procedure.

Conclusions

The long-term course of clinically asymptomatic patients after coarctation patch repair is not uncommonly complicated by formation of TAAs (particularly in individuals with the gothic pattern of the aortic arch) that can be treated effectively with stentgrafts. However, in some patients hybrid procedures may be necessary.

Percutaneous interventions of the aorta

Coarctation of the aorta includes a wide array of anatomical and pathophysiological variations that may cause important long-term morbidity and mortality. Percutaneous techniques, such as balloon dilation and stenting, allow clinicians to safely decrease or abolish most gradients along the aorta, albeit with limitations. Proper patient selection and interventional technique allow clinicians to obtain an adequate stretch or therapeutic tear of the vessel wall, but should avoid complications, such as an excessive tear, dissection, aneurysm formation or rupture. The interventional technique is tailored by patient characteristics such as age, size and growth potential, by characteristics of the lesion such as degree of narrowing, length, angulation(s) and by local regulations.