Endovascular Repair of Rapidly Enlarging Ascending Aortic Pseudoaneurysm
Christian V. Ghincea, T. Brett Reece, Yuki Ikeno, Donald L. Jacobs, Muhammad Aftab.
University of Colorado, Aurora, CO, USA.
BACKGROUND: Surgical repair of rapidly expanding proximal aortic pseudoaneurysms is challenging and carries significant morbidity. We present a case of endovascular repair of a rapidly expanding ascending aortic pseudoaneurysm with mediastinal hematoma in a high-risk patient. METHODS: A 75-year-old male with previous 3-vessel coronary artery bypass grafting and interval development of ascending aortic pseudoaneurysm presented to an outside hospital with ST-elevation myocardial infarction and was found to have rapid expansion of his pseudoaneurysm with contained rupture. After cardiac catheterization, the patient was transferred to our institution for further management. On arrival he had biventricular heart failure with an EF of 25% on echo, respiratory failure, and oliguric renal failure. Given the patient's critical condition, he was a poor candidate for open surgery, so we elected to proceed with an endovascular approach, which was an off-label use of the stent grafts. Operative planning included use of 3D reconstructive software for mapping critical anatomy and landing zones. After femoral arterial access, fluoroscopy and IVUS were used to locate the coronary and innominate artery take-offs, and size the proximal/distal landing zones. Three stent grafts were deployed from the sinotubular junction to proximal the innominate under rapid-ventricular pacing. Completion aortogram and IVUS confirmed patency of the coronaries and the innominate, and exclusion of the pseudoaneurysm.
RESULTS: The patient tolerated the procedure well. Postoperative imaging demonstrated a stable repair of the pseudoaneurysm. He is currently recovering in cardiothoracic intensive care.
CONCLUSIONS: Endovascular repair may be a feasible alternative for high-risk patients with ascending aortic pseudoaneurysm.
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