Title
Percutaneous Closure of An Aortic Pseudoaneurysm Using Coils and an Occluder
Introduction
Aortic pseudoaneurysms are a rare complication of aortic procedures. Main indication of closure includes symptoms and increased risk of rupture. In high risk surgical patients less invasive options of treatment with coil embolization can be considered.
Clinical Case
A 62-year-old female with past medical history of right breast cancer treated with radiation and right lumpectomy, paroxysmal atrial fibrillation, and bicuspid aortic valve stenosis treated with mechanical aortic valve and ascending aortic aneurysm replacement with hemiarch 10 years ago was being followed with serial computed tomography (CT) for a small focal proximal ascending aortic pseudoaneurysm with a normal functioning prosthesis. Pseudoaneurysm size had been stable for years, however, the most recent CT showed an increased size from 1.6x1.5 cm to 3.4x1.7 cm along the posterolateral aspect of the ascending aortic graft suggestive of an expanding pseudoaneurysm. Patient was deemed high re-operative surgical risk. After multidisciplinary team discussion, decision was made to proceed with percutaneous closure with coiling of the pseudoaneurysm and plugging the exit site along the proximal suture line. Procedure was performed under general anesthesia. CT-fluoroscopy fusion imaging was utilized for guidance of the procedure. Segmentation of the CT was performed of the mechanical aortic valve, aorta with great vessels, and pseudoaneurysm with landmarking of the pseudoaneurysm exit site. Registration was achieved using the aortic prosthesis in two views (RAO/LAO) and CT overlay was used for guidance. A 5-Fr 125 cm MPA catheter telescoped in a 6-Fr AL1 guide was used to engage the pseudoaneurysm neck, confirmed by contrast injection. The pseudoaneurysm and exit site were also identified on transesophageal echocardiography (TEE). A 0.035" 260-cm angled stiff Glidewire (Terumo, Somerset, NJ) was then used to access the pseudoaneurysm. The telescoped catheters were exchanged for a 6-Fr 110-cm Flexor Shuttle sheath (Cook Medical, Bloomington, IN). A V-18 Control Wire guidewire (Boston scientific, Maple Grove, MN) was introduced as a safety wire. A 0.021" Rebar-18 microcatheter was positioned in the pseudoaneurysm and coiling performed using framing coils (seven PV-18-40 Concerto PGLA 3D) followed by packing coils (three PV-12-30 Concerto PGLA, two PV-14-30 Concerto PGLA, one NV-10-30 Concerto nylon, one NV-9-30 Concerto nylon helical coils) to obliterate the aneurysm sac. Closure of the exit site was completed using a 6-mm Amplatzer Duct Occluder II (Abbott Cardiovascular, Plymouth, MN). Contrast angiography and TEE confirmed device positioning without contrast extravasation. Follow-up CT revealed a thrombosed pseudoaneurysm.
Discussion
1.Computed tomography is essential for pre-procedural planning to help identify the size and location of both the aortic pseudoaneurysm along with its exit site.
- CT-Fluoroscopy fusion imaging facilitates intra-procedural guidance by selecting optimal C-arm angles and landmarking the pseudoaneurysm and exit site for wire cannulation and subsequent closure of the aneurysmal sac.
- A combined percutaneous approach of pseudoaneurysm closure using coils to fill the aneurysmal sac and an occluder to plug the aortic exit site provides immediate seal and prevents future expansion.