AB

A 44 year old male was diagnosed with severe aortic regurgitation and ascending aorta aneurysm in July 2012. He underwent Bentall��s procedure with composite 23mm St. Jude Mechanical valve & 26mm collagen coated Dacron graft. He was asymptomatic for the past 7 years and had defaulted follow up. Echocardiogram revealed a normally functioning mechanical valve in the aortic position and a large pseudoaneurysm around the ascending aorta graft (Figures 1 & 2).

Cardiac MRI demonstrated a fistulous communication 1.5 x 1.8 cm between the true and false lumen at the posterior aspect of the distal anastomotic site leading to a large pseudoaneurysm of size 5.5cm around the ascending aorta graft (Figure 3). 

The diagnosis of ascending aorta pseudoaneurysm was confirmed by cardiac MRI. This case was discussed in a multidisciplinary meeting with our heart team. The MRI had demonstrated the distal anastomotic site leak into a large pseudoaneurysm through a fistulous tract which was amenable to device closure. Aortic re-operation is associated with high mortality and morbidity. Hence, decision was taken to proceed with percutaneous repair of the aortic pseudoaneurysm.

The procedure was done under general anaesthesia with transesophageal echocardiogram guidance. Right and left femoral arterial access was obtained using modified Seldinger technique. The right common femoral artery was pre-closed with a 6F Perclose ProGlide and upsized to a 10 F sheath. A 6 F sheath was placed in the left common femoral artery. A 5 F Pigtail catheter was advanced through the left common femoral artery and placed in the aortic root. Angiogram demonstrated the ascending aorta pseudoaneurysm (Figure 4). Transesophageal echo showed the pseudoaneurysm with a 16 -18 mm defect in the posterior aspect of the aortic wall. Using a 6F 4.0 Judkins Right catheter and 0.035�� Terumo guidewire, the pseudoaneurysm was successfully cannulated. A 0.035�� super stiff guidewire was exchanged and positioned in the pseudoaneurysm for support. The 10F Amplatzer delivery system was positioned in the pseudo aneurysm over the super stiff Teflon wire. A 24 mm Lifetech ASD occluder was delivered and successfully positioned across the mouth of the pseudoaneurysm (Figures 5 & 6).Correct positioning was confirmed with angiography and transesophageal echocardiogram. Aortic root angiogram showed no residual shunting across the pseudoaneurysm and no obstruction to flow across the aorta (Figures 7 & 8). The delivery system was removed and the Proglide preclose sutures were tied. Complete hemostasis was secured. His vitals were stable throughout the procedure. 

This case demonstrates the successful percutaneous repair of a pseudoaneurysm of the ascending aorta post cardiac surgery using an ASD occluder device. We emphasize the importance of a multidisciplinary heart team approach to decide the best treatment plan for the patient. Redo surgery is associated with high morbidity and mortality. Endovascular stent grafting requires satisfactory landing zones for anchoring. Percutaneous options like placing a covered stent across the neck, device closure and coiling of the pseudoaneurysm sac should be considered. Percutaneous device closure is a low risk suitable alternative procedure in these patients.