‘Aortitis Necessitans:’ Pseudoaneurysm of the Ascending Aorta Eroding Through the Chest Wall
Jonathan M. Hemli, MD, Jui-Chuan Tseng, PA-C, Paley G. Arnone, S. Jacob Scheinerman, MD, Chad A. Kliger, MD, Luigi Pirelli, MD, Craig L. Basman, MD, Nirav C. Patel, MD, Derek R. Brinster, MD.
Lenox Hill Hospital / Northwell Health, New York, NY, USA.
Background Management of a ruptured ascending aorta can be challenging in a patient who has had multiple prior cardiac surgical procedures. We demonstrate an endovascular technique for dealing with a pseudoaneurysm of the ascending aorta that was actively eroding through the chest wall. Methods The illustrative case involves a 59-year-old male with a diagnosis of Goldenhar syndrome and a background of tetralogy repair, an aortic valve replacement, and interval aortic root replacement. Two months prior, he noted a draining sinus through his old sternotomy incision, treated by removal of two sternal wires and application of a vacuum wound dressing. He now presents with chest pain and a rapidly enlarging pulsatile mass on his chest wall at the site of recent sternal debridement. Our technique for addressing this pathology via endovascular means is demonstrated. Results As illustrated in the video presentation, an endovascular stent-graft was successfully deployed in the ascending aorta to seal the defect in the aortic wall. The sternum itself was debrided in a separate procedure and the defect was covered with omentum and a skin graft. The patient recovered without complication. Progress imaging confirms the integrity of the ascending aorta and complete exclusion of the false aneurysm from the circulation. Conclusions Endovascular occlusion of a ruptured ascending aorta may successfully seal the defect and achieve a satisfactory clinical outcome and may be useful in a patient in whom a reoperation would be particularly challenging in an acute setting.
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