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JACC Case Rep
JACC Case Rep
JACC Case Reports
2666-0849
Elsevier

S2666-0849(24)00257-2
10.1016/j.jaccas.2024.102464
102464
Coronary, Peripheral, and Structural Interventions
Case Report: Clinical Case
Atrial Septal Defect Occlusion Device Closure of Ascending Aortic Pseudoaneurysm
Can Percutaneous Treatment Become the Solution?
Cabrita André MD afocabrita@gmail.com
a∗
Tavares Silva Marta MD, PhD ab
Amaral Marques Catarina MD a
Silva João Carlos MD a
Vasconcelos Mariana MD a
André Rodrigues Rui MD a
a Cardiology Department, ULS São João, Porto, Portugal
b UnIC@RISE, Faculty of Medicine, Department of Surgery and Physiology, University of Porto, Porto, Portugal
∗ Address for correspondence: Dr André Filipe Oliveira Cabrita, Cardiology Department, ULS São João, Rua do Picoto nº 284 4º Trás, 4780-521, Santo Tirso, Portugal. afocabrita@gmail.com
21 8 2024
21 8 2024
21 8 2024
29 16 1024648 4 2024
9 5 2024
18 6 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This paper presents 2 cases of middle-aged men submitted to aortic valve replacement surgery that were complicated with ascending aortic pseudoaneurysms treated percutaneously with an atrial septal defect occlusion device (Amplatzer, Abbott Cardiovascular). Percutaneous closure may be an effective treatment in selected patients with high surgical risk.

Graphical Abstract

Key Words

Amplatzer Septal Occluder
aortic percutaneous treatment
aortic pseudoaneurysm
aortic surgery
atrial septal occluder
Abbreviations and Acronyms

AAP ascending aortic pseudoaneurysm

ASD atrial septal defect

CTA computed tomography angiography
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pmcAortic pseudoaneurysm is defined as a dilation of the aorta due to disruption of all wall layers, which is only contained by periaortic connective tissue. Ascending aortic pseudoaneurysms (AAPs) present mostly as a rare complication of cardiac or aortic surgery but can also derive from other etiologies (eg, thoracic trauma, inflammation, infection).1 AAPs are associated with an increased risk of mortality and morbidity due to rupture, thrombosis and distal embolization, fistula formation, among others.1Learning Objectives

• To be able to make a differential diagnosis of aortic valve surgery complications with multimodality imaging.

• To recognize that in selected patients with high surgical risk and favorable anatomic characteristics, percutaneous closure of AAP could be considered.

• To understand that percutaneous treatment of AAP should be individualized according to the lesion location and size.

The incidence of AAPs is uncertain. They have been reported to be as low as 0.5%, but one surveillance imaging series found an incidence of up to 13% after cardiac or aortic surgery. Pseudoaneurysms are typically asymptomatic at first, but various symptoms may arise due to compression of surrounding structures (eg, dyspnea, chest pain, syncope). Mortality ranges from 29% to 46%, being exsanguination due to rupture of the pseudoaneurysm the most frequent cause of death.2

Computed tomography angiography (CTA) is the recommended diagnostic test to exclude postsurgical AAPs and may allow to establish the location, number, and size of the leaks.3 For perioperative planning, 3-dimensional CTA reconstructions are the gold standard.3

In patients with AAP, invasive treatment (surgery or endovascular intervention) is always indicated, regardless of size. The choice between surgical or percutaneous treatment is based on surgical risk and anatomic characteristics.3 Surgical repair is the gold standard treatment but is associated with high mortality (around 40%) and morbidity. It requires redo sternotomy and cardiopulmonary bypass for suture or patch repair.1 Alternatively, percutaneous closure may be an effective treatment in selected patients. Several types of endovascular treatment have been reported in the literature, but they have been mostly restricted to cases when traditional surgery imposes a prohibitive risk.2 Experience in percutaneous treatment of AAPs is still scarce and heterogeneous.1 Case reports demonstrate the use of different devices, including septal occluders, vascular plugs, stent grafts, or coil embolization, which are selected individually according to the size and shape of the pseudoaneurysm because there are no devices specifically built to treat this complication percutaneously.

We present 2 cases of AAPs treated percutaneously with an atrial septal defect (ASD) occlusion device (Amplatzer Septal Occluder, Abbott Cardiovascular).

Case 1

A 53-year-old man presented with a history of cardiovascular risk factors, namely hypertension and smoking, and a type II DeBakey aortic dissection submitted to a Bentall procedure with a mechanical aortic valve prosthesis, anticoagulated with warfarin. Five years later, he was admitted for chest pain. CTA revealed an acute dissection involving descending thoracic and abdominal aorta and a 16 × 11 mm AAP (Figure 1) distal to the graft. A percutaneous treatment was planned; therefore, warfarin was switched for low molecular weight heparin. Four days later, the preprocedural angiography confirmed spontaneous closure of the AAP (Video 1); therefore, no intervention was performed. At follow-up consultations, the chronic aortic dissection and AAP remained stable (Figure 2) and without symptoms. Five years later, the patient was readmitted for chest pain, with unremarkable vital signs and physical examination. At this time, CTA revealed an aggravation to a giant 65 × 50 mm AAP (Figure 3) with active contrast extravasation distal to the ascending aortic graft and a periprosthetic intramural hematoma, with overlapping findings in the descending thoracic and abdominal aorta. Considering the high risk of cardiac surgery (EuroSCORE II 16.2%), a multidisciplinary team opted to do a percutaneous closure. The procedure was performed under local anesthesia, through a 6-F femoral artery access. Under fluoroscopic guidance, the first step was to perform aortography with a pigtail catheter to locate the AAP and to measure its neck (14 mm) (Figure 4). Second, a 6-F coronary guiding catheter was used to probe the AAP and inject contrast to define its dimension. Then, an ASD occlusion device (15 mm diameter) was successfully deployed. Finally, another angiography with a pigtail catheter revealed the persistence of mild residual leak (Video 2). The symptoms disappeared, but a CTA performed 2 days later still demonstrated a slight communication between the ascending aortic lumen and the pseudoaneurysm with a neck of 10 mm, which was significantly smaller (36 × 20 mm on axial axis). Four months later, the patient developed chest pain and hoarseness and CTA documented pseudoaneurysm growth; therefore, the patient was treated with an E-vita (Artivion, Inc) thoracic endoprosthesis. In the following year, the patient suffered syncope with documentation of a high-degree atrioventricular block, and a single-chamber pacemaker was implanted. A year later, the descending thoracic and abdominal aorta chronic dissection aggravated, so the patient was submitted to thoracic endovascular aortic repair from aortic arch to celiac trunk with debranching to supra-aortic vessels. A few months later, he was hospitalized for fungal endocarditis due to Candida parapsilosis, which was successfully treated with fluconazole. At 3-year follow-up, the patient remains clinically well and without relapses.Figure 1 Computed Tomography Angiography Diagnosing Ascending Aortic Pseudoaneurysm

Arrows point to ascending aortic pseudoaneurysm (16 × 11 mm).

Figure 2 Computed Tomography Angiography Demonstrating Stable Ascending Aortic Pseudoaneurysm and Aortic Periprosthetic Hematoma

Arrow points to stable ascending aortic pseudoaneurysm.

Figure 3 Computed Tomography Angiography Revealing Giant Ascending Aortic Pseudoaneurysm

Arrow points to giant (65 × 50 mm) ascending aortic pseudoaneurysm.

Figure 4 Angiography Demonstrating Measurement of the Ascending Aortic Pseudoaneurysm’s Neck (14 mm)

Arrow points to ascending aortic pseudoaneurysm's neck.

Case 2

A 67-year-old man was hospitalized due to acute de novo heart failure. The patient did not present any history of previous cardiac disease. Echocardiogram revealed dilated heart chambers, an aneurismatic ascending aorta (50 mm) with severe central aortic regurgitation, and moderate mitral and tricuspid regurgitation with severely reduced left ventricular ejection fraction. Coronary angiography revealed moderately obstructive disease on left anterior descending artery. The patient was submitted to aortic valve replacement with a biological prosthesis (PERIMOUNT Magna Ease 27, Edwards Lifesciences) and mitral and tricuspid annuloplasty, but the aneurismatic ascending aorta was not intervened. The patient developed postsurgery paroxysmal atrial fibrillation but demonstrated a favorable evolution. Nine days later, the patient was discharged on warfarin. One month later, the patient presented an episode of presyncope, with unremarkable vital signs and physical examination. CTA revealed a stable aneurismatic ascending aorta (50 mm) with an anterior pseudoaneurysm (20 × 22 mm) with no signs of active bleeding (Video 3). To avoid the high risk of another surgery (EuroSCORE II 31.7%), a multidisciplinary team decided to perform a percutaneous repair. Under local anesthesia, a 7-F femoral artery access was obtained and a 7.5-F sheathless JR 4 coronary guiding catheter was used to probe the focal leak and inject contrast to measure the neck of the AAP under fluoroscopic guidance (Video 4). After that, an ASD occlusion device (8 mm diameter) was successfully deployed (Video 5). A pigtail catheter was inserted to perform aortic angiography and exclude any residual leak. CTA confirmed pseudoaneurysm exclusion (Figure 5), and the patient was later discharged without symptoms. At 4-month follow-up, the patient remains clinically stable.Figure 5 Postprocedural Computed Tomography Angiography Confirmed Pseudoaneurysm Exclusion

Arrow points to atrial septal defect occlusion device.

Discussion

Although AAPs are unusual, they are associated with an increased risk of rupture, thrombosis, distal embolization, and death. They frequently arise from cannulation sites, aortic perfusion catheters, saphenous vein grafts conduits origin, cardioplegia cannulation, and aortotomy sites from aortic valve replacement during cardiopulmonary bypass.4

Open surgical repair is considered standard of care but can be technically difficult and has substantial risk of morbidity and mortality.4 Traditional management of AAPs has been redo sternotomy and open repair of the pseudoaneurysm with either suture or patch closure.1

In high surgical risk patients, an endovascular approach represents a viable option.2 Due to its low incidence, data are sparse and come from clinical case reports. Because AAPs can occur in different locations imposing specific anatomic challenges, there is no standard percutaneous approach or dedicated device. Different case series report the use of different techniques, including implantation of septal occluders, vascular plugs, stent grafts, or coil embolization.3

The composite success rate for percutaneous closure of AAP using all available devices is around 80%, and an ASD occluder device is the most economic and straightforward approach for percutaneous AAP closure. With this strategy, the critical factor determining suitability for closure is the diameter of the neck, not the overall size of the AAP.4

In these 2 cases, the percutaneous approach offered a low-risk procedure using local anesthesia and femoral access, with a high probability of success due to anatomic characteristics (focal small leak with a thin neck). We chose ASD occlusion devices because of its 2 flexible and symmetrical retentional disks. Potential complications of these procedures include incomplete closure of the defect and embolization of the device into the AAP or even to systemic circulation. In our experience, we have found this device safe and useful compared with other percutaneous techniques. The choice of treatment for AAP should be individualized, based on anatomical features, clinical presentation, and comorbidities.

Because of the paucity of long-term survival data, percutaneous therapies to correct AAPs are not generally recommended as a primary therapy. Long-term multicenter data on involving transcatheter procedures can provide essential information and comparison with the current gold standard therapy.4

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Angiography Demonstrating Spontaneous Closure of the Ascending Aortic Pseudoaneurysm

Video 2

Percutaneous Closure of the Ascending Aortic Pseudoaneurysm With 15-mm Atrial Septal Defect Occlusion Device, Revealing a Slight Residual Leak

Video 3

Three-Dimensional Computed Tomography Angiography Revealing an Aneurismatic Ascending Aorta (50 mm) With an Ascending Aortic Pseudoaneurysm (20 × 22 mm)

Video 4

Measurement of the Ascending Aortic Pseudoaneurysm’s Neck Under Fluoroscopic Guidance

Video 5

Percutaneous Closure of Ascending Aortic Pseudoaneurysm With 8-mm Atrial Septal Defect Occlusion Device, Without Residual Leak

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Appendix

For supplemental videos, please see the online version of this paper.
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References

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