A giant transsternal aortic pseudoaneurysm

Aortic pseudoaneurysm is a rare but life-threatening complication after a cardiac surgery. Potential mechanisms are suture dehiscence, iatrogenic trauma and poor quality of aortic tissues. Most cases are diagnosed in the first months after the surgery and are due to an infectious process. Here, we report a case of transsternal aortic pseudoaneurysm after an aortic valve replacement surgery and we describe our surgical approach. This case is exceptional for its late timing and presentation with a pulsatile sternal mass.

Pseudoaneurysm with a fistula to the right ventricle late after surgical repair of type A aortic dissection in a patient with systemic lupus erythematosus

Background

Pseudoaneurysm with a shunt to the right ventricle after aortic repair for acute aortic dissection is an extremely rare and life-threatening condition. Surgical treatment is unavoidable, but surgery is complicated, and there are some pitfalls. This study describes the reoperation performed in a patient at a high surgical risk by clarifying the shunt site using multimodality imaging before surgery.

Case presentation

A 69-year-old woman with a history of systemic lupus erythematosus (SLE) and Sjogren’s syndrome presented with a pseudoaneurysm 1 year after emergency surgery for acute type A aortic dissection. Eight years after the first surgery, she experienced sudden chest pain and presented to the emergency department. Her dyspnea worsened; therefore, echocardiography and three-dimensional computed tomography (3DCT) were performed, and a pseudoaneurysm and shunt to the right ventricle were identified. The medical team attempted to close the shunt with a percutaneous catheter but was unsuccessful, and she was referred to our department for surgical treatment. The pseudoaneurysm originating from the proximal side of the aorta was large (diameter = 55 mm), and echocardiography-gated 3DCT identified the shunt from the pseudoaneurysm to the right ventricle. First, extracorporeal circulation was initiated, and resternotomy was performed. We could not insert the left ventricular venting tube from the right side because of the pseudoaneurysm size. Instead, the tube was inserted from the left atrial appendage. We found a half-circumferential disengaged anastomosis around the proximal anastomosis, which formed the large pseudoaneurysm leading to a fistula in the right ventricle. We closed the fistula and performed a Bentall operation. The patient had a good postoperative course and was discharged on postoperative day 21. She continued treatment for SLE and Sjogren’s syndrome, and her inflammatory reaction improved.

Conclusions

We performed a Bentall operation and fistula closure with resternotomy in a patient with type A aortic dissection with SLE and Sjogren’s syndrome. Multimodal imaging is essential in defining the pseudoaneurysm and the fistula surrounding the anatomy while ensuring their resolution and guiding the approach for operation.

3D model-guided transcatheter closure of ascending aorta pseudoaneurysm with the novel Amplatzer Trevisio intravascular delivery system

Ascending aorta pseudoaneurysm (AAP) is a rare but life-threatening complication of atherosclerosis, endocarditis, chest trauma, transcatheter or cardio-thoracic procedures. Since surgical repair is burdened by high morbidity and mortality, percutaneous closure is nowadays considered a valuable cost-effective therapeutic alternative. Due to unpredictability and complexity of local anatomy, no standardized technique and device are advised. In this setting, 3D printing technology could significantly help in planning trans-catheter approach. This article reports on a 3D printed model-guided percutaneous closure of a huge AAP using an Amplatzer Septal Occluder (Abbott, Plymouth MN) implanted by the recently commercialized Amplatzer Trevisio Intravascular Delivery System.

Percutaneous Closure of a Giant Aortic Pseudoaneurysm Using Multimodality Imaging Guidance

Ascending aortic pseudoaneurysm is a rare, life-threatening complication of cardiac surgery. Surgical management is recommended, however, transcatheter techniques offer a less invasive alternative. We describe successful percutaneous closure, guided by using multimodality imaging, in a patient with high surgical risk.

Surgical management of a pulsatile chest wall mass secondary to an ascending aortic aneurysm in a patient with bovine arch

Ascending aortic pseudoaneurysms are rare, but life-threatening conditions, that often require intervention. While endovascular techniques have advanced significantly, the majority of these clinical scenarios preclude endovascular options and the primary treatment modality remains open surgical repair. Repair of an aortic pseudoaneurysm eroding through the sternum resulting in a pulsatile chest wall mass is technically challenging. We report the successful repair of a large ascending aortic pseudoaneurysm in a 62-year-old male with bovine arch anatomy and prior Type A dissection repair, presenting with contained rupture and a pulsatile chest wall mass.

Repair of ascending aortic pseudoaneurysm eroding through the sternum

In reoperation for an ascending aortic pseudoaneurysm eroding through the sternum, a left ventricular vent allows careful unhurried sternal division under deep hypothermic circulatory arrest. We repaired ascending aortic pseudoaneurysms in 2 patients who had undergone aortic valve implantation 6 and 21 months earlier. A minithoracotomy was made in the left 5th intercostal space, and a vent was placed in the left ventricular apex. Repair was accomplished with a bovine pericardial patch reinforced with a Teflon felt strip. Both patients made an uneventful recovery with good functional status at discharge at the 8- and 18-month follow-up.

Hybrid Procedure with Debranching from the Descending Aorta for Aortic Arch Aneurysm after Previous Open Repair

Aortic arch aneurysms can be treated with hybrid procedures by endovascular exclusion and prior debranching of supra-aortic arteries. We report on a case of symptomatic arch aneurysm following previous supracoronary ascending aorta and hemiarch replacement with a very short proximal landing zone. A successful reconstruction was performed by retrograde revascularization of supra-aortic vessels from the descending aorta and subsequent endovascular repair deploying a proximal stent graft directly above the sinotubular junction with good results in the 4-year follow-up. Retrograde supra-aortic debranching may constitute a suitable approach for hybrid endovascular repair of aneurysms of the aortic arch and the ascending aorta in selected cases.