Atrial septal defect occluder combined with stent graft for the management of post-dissection aortic aneurysm previously treated with unsuccessful coils: a case report

BACKGROUND

Although the candy-plug technique has been reported to be useful for the treatment of post-dissection aortic aneurysm, the stent graft needs be to customized to accommodate the size of vascular occluders.

CASE PRESENTATION

We present a case of a persistent false lumen successfully treated with endovascular stent-graft and atrial septal defect occluder in a patient with Stanford Type B dissection. A covered stent graft was implanted into the false cavity through a distal rupture, and an atrial septal defect occluder was inserted into the covered stent to seal of the false cavity. Decreased aneurysmal diameter and false lumen thrombosis were noted by CT scan at 6-month follow-up.

CONCLUSIONS

Our case showed that combined use of a stent graft and atrial septal defect occluder is safe, technically feasible and effective in sealing of the false lumen in post-dissection aortic aneurysm patients with previously failed false lumen thrombosis.

Aortic remodeling after false lumen occlusion using an atrial septal occluder in chronic DeBakey IIIb aortic dissection

OBJECTIVE

Retrograde false lumen flow through distal entry tears poses a challenge in the treatment of chronic DeBakey IIIb aneurysms. In the present report, we have described the feasibility and outcomes of false lumen occlusion using an atrial septal occluder (ASO) in chronic DeBakey IIIb dissection associated with a descending aneurysm.

METHODS

All the patients who had undergone thoracic endovascular aortic repair for chronic DeBakey IIIb aortic dissection at our institution from January 2014 to November 2020 were retrospectively reviewed. The primary endpoints were technical success and in-hospital postoperative results. The secondary endpoints included the midterm survival status and aortic remodeling outcomes.

RESULTS

A total of 37 patients (age, 56.24 ± 10.47 years) with persistent retrograde false lumen perfusion and aneurysm formation at the thoracic segment were treated using an ASO for false lumen occlusion. We achieved 100% technical success. No spinal cord ischemia or in-hospital death was observed. The median follow-up time was 36 months (interquartile range, 24-51 months). After the procedure, three patients (8.1%) had had an endoleak (type Ia in two patients and type II in one patients), and five patients had required late reintervention. The overall 5-year survival rate was 71%. One aortic-related death (2.7% of the total cohort) occurred during follow-up at 9 months. Complete thrombosis of the false lumen along the treated aortic segment was recorded postoperatively in 34 patients (91.9%) at the final follow-up using computed tomography angiography. In a mixed-effects model, a diameter analysis revealed that the thoracic true lumen diameter had increased and the thoracic false lumen diameter had decreased significantly (0.256 mm/mo, P < .001; and -0.512 mm/mo, P < .001, respectively).

CONCLUSIONS

The combination of standard thoracic endovascular aortic repair and false lumen occlusion using the ASO to promote false lumen thrombosis and remodeling in the treated segments is a technically feasible and effective alternative treatment of chronic DeBakey IIIb dissection with an associated descending aneurysm. This approach yielded satisfactory midterm survival outcomes and a low incidence of aortic-related death in our patients. However, further studies with more subjects and a prospective design should verify our findings before routine clinical implementation of this technique.

Multistage closure of a congenital extrahepatic portosystemic shunt

Background

Congenital extrahepatic portosystemic shunts (CEPS) are rare shunts connecting the extrahepatic portal system with the inferior vena cava. Shunt dimensions and the risk of portal hypertension determines the closure strategy. Endovascular treatment is indicated for single stage occlusion of longer length shunts, whereas the remaining shunt types are preferentially surgically occluded. Herein we describe the technical details of a novel endovascular treatment for short length CEPS.

Case presentation

A 15-years-old male with a short length CEPS complicated with multinodular liver disease was submitted to a multistage closure, as indicated by the high portal pressure values during shunt balloon occlusion venography. Initially a transjugular intrahepatic portosystemic shunt (TIPS) was created and the CEPS occluded with an atrial septal defect occluder. In a second procedure the TIPS was embolized with a flow reductor stent and an amplatzer vascular plug II. At a 1 year follow up the liver nodules size reduced, the patient remains asymptomatic, and the shunt adequately closed.

Conclusion

This paper outlines the potential use of a TIPS and an atrial septal defect occluder combination in complex CEPS, supporting its usage as an alternative to the standard surgical treatment.

Level of Evidence: Level 4, Case report.

Deployed Dimensions of the GORE® CARDIOFORM ASD Occluder as Function of Defect Size

The GORE® CARDIOFORM ASD occluder (ASDO) is approved for closure of ASDs up to 35 mm diameter. With an adaptable central waist, each device size is suitable over a range of defect diameters. Understanding deployed dimensions across various defect sizes will assist operators. Therefore, this study investigates the deployed dimensions of the ASDO as a function of defect size. A 2-mm-thick ASD model with circular defects ranging from 5 to 35 mm was 3D printed. Diameter, width, and left-right disc diameter were measured by fluoroscopy after ASDO devices were deployed in applicable defects. Linear regression evaluated relationships between device size, defect size, and deployed dimensions. Six ASDOs of each size (27, 32, 37, 44, and 48 mm) were deployed in all applicable defects. There was significant ASDO size-defect size interaction in determining deployed ASDO diameter. Diameter was positively associated with defect size for 48-mm (B = 0.13, p < 0.001) and 44-mm (B = 0.11, p < 0.001) ASDOs, while no association was seen for 27-mm, 32-mm, or 37-mm ASDOs. No such interaction existed for deployed width or left-right disc difference. Controlling for ASDO size, width (B = - 0.12, p < 0.001) and left-right disc difference (B = - 0.06, p < 0.001) were negatively associated with defect size. In smaller defects, the 44-mm and 48-mm ASDOs display progressive diameter foreshortening, and all devices display progressive increase in width and left-right disc asymmetry. Anticipating the degree of diameter foreshortening may be critical when attempting closure of fenestrated lesions and/or in patients with limited total atrial septal length.

Completed atrioventricular block induced by atrial septal defect occluder unfolding: A case report

BACKGROUND

An atrial septal defect is a common condition and accounts for 25% of adult congenital heart diseases. Transcatheter occlusion is a widely used technique for the treatment of secondary aperture-type atrial septal defects (ASDs).

CASE SUMMARY

A 30-year-old female patient was diagnosed with ASD by transthoracic echocardiography (TTE) 1 year ago. The electrocardiogram showed a heart rate of 88 beats per minute, normal sinus rhythm, and no change in the ST-T wave. After admission, TTE showed an atrial septal defect with a left-to-right shunt, aortic root short-axis section with an ASD diameter of 8 mm, a parasternal four-chamber section with an ASD diameter of 9 mm, and subxiphoid biatrial section with a diameter of 13 mm. Percutaneous occlusion was proposed. The intraoperative TTE scan showed that the atrial septal defect was oval in shape, was located near the root of the aorta, and had a maximum diameter of 13 mm. A 10-F sheath was placed in the right femoral vein, and a 0.035° hard guidewire was used to establish the transport track between the left pulmonary vein and the inferior vena cava. A shape-memory alloy atrial septal occluder with a waist diameter of 20 mm was placed successfully and located correctly. TTE showed that the double disk unfolded well and that the clamping of the atrial septum was smooth. Immediately after the disc was revealed, electrocardiograph monitoring showed that the ST interval of the inferior leads was prolonged, the P waves and QRS waves were separated, a junctional escape rhythm maintained the heart rate, and the blood pressure began to decrease. After removing the occluder, the elevation in the ST segment returned to normal immediately, and the sinus rhythm returned to average approximately 10 min later. After consulting the patient’s family, we finally decided to withdraw from the operation.

CONCLUSION

Compression of the small coronary artery, which provides an alternative blood supply to the atrioventricular nodule during the operation, leads to the emergence of a complete atrioventricular block.

Closure of Nonmalignant Tracheoesophageal Fistula Using an Atrial Septal Defect Occluder: Case Report and Review of the Literature

Tracheoesophageal fistula (TEF) is a life-threatening condition for which there are several management techniques. We present a case of nonmalignant TEF closure using an atrial septal defect (ASD) occluder. A 53-year-old man with a severe TEF was admitted to our hospital for TEF caused by stenting of an esophagogastric anastomotic stricture. He was successfully treated with closure of the TEF using an endotracheal ASD occluder. Three hundred and eighteen days after placement of the occluder, he suddenly developed a severe cough after dilatation of the esophagogastric anastomosis and spontaneously coughed out the occluder. The fistula was repaired and complete closure that was confirmed on esophagography. He had no recurrence of fistula during the follow-up period of 13 months.

Closure of a broncho-pleural fistula using an atrial septal defect occluder

Broncho-pleural fistulae (BPF) are recognised as a rare complication following pneumonectomy. We describe a patient, who after failing conservative treatment, underwent closure of a persistent fistula with an atrial septal defect (ASD) occluder. Additionally we review the literature regarding management of BPF and the emerging role of cardiac defect closure devices as a possible treatment option.