ABSTRACT: Open surgical repair remains the standard of care for treatment of pseudoaneurysms. However, given the significant risks of surgery, a limited number of recent case reports and small series describe percutaneous approaches to management of aortic pseudoaneurysms with stent-grafts, coils, and occluders.^1-4 We report a case of closure of an aortic pseudoaneurysm with a novel occluder, the Amplatzer Vascular Plug 4 (St. Jude Medical).

VASCULAR DISEASE MANAGEMENT 2016;13(2):E53-E57

Key words: aneurysm repair, interventional cardiology, thoracic aortic aneurysm

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An aortic pseudoaneurysm (PSA) can occur after aneurysm or dissection repair, coronary artery bypass graft surgery, chest trauma, or aortic valve endocarditis.⁵ Untreated PSAs carry a high mortality rate.⁶ Open surgical repair remains the standard of care for treatment of PSAs; however, surgery is associated with significant morbidity and mortality. An alternative to open surgical repair, a percutaneous approach to management of aortic PSA, has been previously reported with stent-grafting, coils, and occluders.⁷ We report a case of closure of an aortic PSA with a novel, fourth generation, occluder, the Amplatzer Vascular Plug 4 (St. Jude Medical).

Case Presentation

A 57-year-old male presented to his nearest hospital with acute onset of chest pain. His past medical history was significant for a type A aortic dissection repair with a 24 mm Dacron Hemashield graft (Maquet) 2 years prior and subsequent sternal wound infection requiring debridement. Afterward, he developed restrictive physiology and underwent a pericardial stripping via thoracotomy. Computed tomography (CT) scan revealed a large PSA (Figure 1) with a discrete and narrow entry point arising from the ascending aorta near the previous suture line that was confirmed by transesophageal echocardiography (Figure 2). The patient was transferred to our institution for further management. In light of his complex surgical history, a percutaneous transcatheter approach was chosen.

Technique

The procedure was performed in the cardiac catheterization laboratory with the patient under conscious sedation. A 6 Fr sheath was placed in the right common femoral artery. Aortic arch angiography was performed with a 6 Fr pigtail catheter and selective angiography confirmed a large ascending aortic PSA (Figure 3).

The patient was given 7,500 units of intravenous heparin and a 5 Fr SIM-1 catheter (Cook Medical) was advanced over a standard .035˝ x 260 cm guidewire into the ascending aorta. The catheter was used to selectively cannulate the ostium of the PSA (Figure 3). A .035˝ x 260 cm straight soft Glidewire (Terumo Medical) was advanced into the PSA (Figure 4). The SIM-1 catheter was exchanged out for a 0.44˝ x 130 mm DAC catheter (Concentric Medical), which was advanced over the wire into the PSA.

The glidewire was removed and a 6 mm Amplatzer Vascular Plug 4 (VP4; St. Jude Medical) was advanced through the DAC catheter and half of the device was exposed in the PSA. The device was pulled back so that the second dome was exposed on the aortic side (Figure 5). Aortography was performed to demonstrate occlusion and the device was assessed for stability. Once stability and closure were confirmed, the device was released. Repeat aortography revealed no residual leak (Figure 6). There were no complications of the procedure and the patient did well post-procedure. This patient received standard post aortic dissection follow-up with CT angiogram at discharge, CT angiogram 1 month after discharge, and then subsequent yearly CT angiograms. No subsequent bloodwork was performed.

Discussion

The etiologies of ascending aortic PSA are numerous and include surgery, trauma, infection, and autoimmune and inflammatory origin.^5,8-10 Possible mechanisms for postsurgical pseudoaneurysm formation include graft infection, dissected native aorta, and tissue necrosis after excessive use of biologic glue.⁸ Positive blood cultures can confirm an infectious origin, and were found in 3 out of 10 patients in a case series of 10 patients who were reoperated after postsurgical false aneurysm.⁸ However, up to 25% of cases of aortitis may present with normal blood cultures.¹⁰ Blood cultures were performed on this patient and the results were negative. There were also no signs of infection (no fever, tachycardia, or leukocytosis). This patient was treated preoperatively with vancomycin and piperacillin-tazobactam, because any delay in treatment, even in the absence of positive blood cultures, would have been catastrophic. While antibiotics are important, even in the face of negative cultures, surgical intervention is imperative. If left surgically untreated, a PSA may result in rupture, thromboembolism, and fistula formation.¹¹ The long-term prognosis of these repairs is unknown, but similar case reports describe no complications in the first year.¹²

While surgical repair is the first-line treatment, this patient had undergone prior repair of type A dissection with sternal flaps and pericardial stripping. Therefore, the risks of performing a reoperation were significant. Prior reports have described closure of PSA with septal occluders, vascular plugs, endovascular stents, or coils. Closure with septal occluders or prior versions of vascular plugs require at least a 6 Fr delivery catheter, which may be difficult to advance to the neck of the pseudoaneurysm. Furthermore, septal occluders and other plugs may have larger surface areas whose long-term effects, such as vascular erosion, are unknown. After eliminating surgical intervention due to prohibitive risks, we opted for endovascular repair with the Amplatzer VP4 occlusion device.

The VP4 is a self-expanding nitinol mesh occlusion device attached to a 155 cm delivery cable. The VP4 has high technical success rates, and the ability to recapture and reposition gives the device an advantage over coils or stents.¹³ The device can also be deployed without using a guide catheter, giving it additional clinical reach. As such, it has been used for splenic artery embolism,¹⁴ internal carotid artery occlusions for tumor treatment,¹⁵ and the treatment of congenital heart defects.¹⁶ Its low-profile design not only confers deliverability via a 4 Fr or 5 Fr diagnostic catheter but also, given the smaller surface area, decreases the risk of erosion. The added advantage of the VP4 over previous generations of the device is the decrease in size of the delivery system, allowing use of the device in much smaller vessels.¹³

Here we present a case of aortic PSA repair with an Amplatazer VP4 that, to the best of our knowledge, has not been previously reported in the literature. In our experience, this novel device is a safe endovascular alternative to treat postsurgical aortic PSA in patients who meet the following criteria: (1) no active infection; (2) adequate access via the femoral vessels; (3) encouraging analysis of the access site with special consideration of the feasibility of device deployment; and (4) presence of an enlarged aorta in which aortic endograft deployment is not feasible. Because of the novelty of the device, its use should be considered on a case-by-case basis. Patients who have already undergone a previous thoracic surgery are at increased risk of morbidity and mortality with a repeat surgical intervention. As the use of the Amplatzer VP4 is expanded and vascular specialists gain experience with the device in this setting, the device may prove particularly useful for the treatment of aortic pseudoaneurysm, even as a first-line treatment option over open surgery.

Editor’s note: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content herein.

Manuscript received July 1, 2014; provisional acceptance given September 30, 2014; manuscript accepted November 9, 2015.

Address for correspondence: Mark J. Russo, MD, MS, Barnabas Heart Health Centers Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, 201 Lyons Ave, Suite G5, Newark, NJ 07112, United States. Email: mr2143@gmail.com. 

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