Case Report
The patient is a 35 year-old man with Type II Diabetes Mellitus,
hypertension, hyperlipidemia, and morbid obesity (BMI 37) who presented
in 2009 with a symptomatic 7.7 cm ascending aortic aneurysm. He had no
prior history of cardiac disease, no family history of connective tissue
disorders and no history of aortopathy. At his initial presentation, the
patient presented with severe palpitations and was found to have severe
aortic insufficiency (AI) with an annular diameter of 33mm and preserved
left ventricular (LV) function. He underwent a “Modified Bentall”
composite aortic root replacement via median sternotomy and
cardiopulmonary bypass[1]. Arterial cannulation was achieved via the
femoral artery and right atrium, retrograde cardioplegia was
administered via the coronary sinus and the LV was vented via the right
superior pulmonary vein. The aorta was cross-clamped proximal to the
innominate artery. A #31 composite St. Jude mechanical valve conduit
was used. The proximal anastomosis was completed using interrupted
sutures while the distal anastomosis was performed using a running
suture repair with pledgeted reinforcement. Coronary buttons were
fashioned and anastomosed to the graft conduit. An intraoperative
transthoracic echocardiogram (TEE) showed no paravalvular leak. The
patient had an unremarkable postoperative course and was progressing
well at follow-up.
Ten months post-procedure the patient presented to the emergency
department with complaints of chest pain. Imaging with a computed
tomography with arterial phase contrast (CTA) revealed contrast
extravasation at the level of the aortic annulus suggesting an
anastomotic pseudoaneurysm; however, transthoracic echocardiography
(TTE) at this time did not show evidence of flow into this space (Figure
1). His symptoms resolved and no intervention was undertaken at this
time. The patient was followed with serial CTAs.
Eight years following his repair, our patient was found to have
pseudoaneurysm enlargement on surveillance CTA from his prior imaging,
and again endorsed symptoms of intermittent chest pain (Figure 2). He
underwent TEE which the previously identified pseudoaneurysm at the
level of the proximal anastomosis in the interatrial septum. Left heart
catheterization was subsequently performed and confirmed the
extravasation of contrast proximal to the mechanical valve and into the
pseudoaneurysm space (Figure 3).
The patient was discussed in multidisciplinary conference including
cardiology, interventional cardiology, cardiac surgery, and
anesthesiology. Re-operation for pseudoaneurysm repair was weighed
against percutaneous endovascular repair and discussed with the patient
and the decision was made to pursue percutaneous closure of the defect.
The procedure was performed under general anesthesia with intraoperative
TEE guidance. Two transseptal punctures were performed for angiography
and for device deployment via an 8.5-Fr sheath in the right femoral
vein. The pseudoaneurysm space was accessed using a 6-Fr glide catheter
and angled glidewire. The defect size was measured approximately 10mm. A
14mm AmplatzerTM Vascular Plug II (Abbott
Laboratories; Chicago, IL) was placed, however persistent leak was
noted. An 8mm AmplatzerTM Septal Occluder (Abbott
Laboratories; Chicago, IL) device was then deployed. This resulted in a
stable position of the plug and moderately improved the leak by color
flow and angiography. TEE confirmed residual but significantly improved
shunt flow. The procedure was concluded and the patient was admitted
post-procedurally for observation. A TEE was repeated on post procedure
day one and showed the vascular plug near in appropriate position with
residual trace AI observed. The patient recovered uneventfully and
underwent repeat TTE at 3 month follow-up.
TTE at follow-up revealed no obvious AI in the area of the device and
the previous pseudoaneurysm was no longer evident. The patient also
underwent a follow-up CTA at that time and the previously seen
extraluminal contrast collection was no longer present. Specifically,
the previously seen pseudoaneurysm abutting the aortic root had
decreased in size and thrombosed (Figure 4). The patient has resumed
regular activity and remains free of recurrence two years following his
intervention.