Percutaneous Approach for Treating Aneurysmal Dilatation and Coarctation in a Patient with Complex Double Aortic Arch Anatomy

P0252 

Case Video Submission 

Bo Chang Wu (1), Adam Carroll (1), Nicolas Chanes (1), Jessica Rove (2), Joseph Cleveland (3), Muhammad Aftab (4), T. Brett Reece (3)

(1) University of Colorado Anschutz, Denver, CO, (2) University of Colorado Anschutz Medical Center and Rocky Mountain Regional VAMC, Aurora, CO, (3) University of Colorado Hospital, Aurora, CO, (4) University of Colorado, Anschutz Medical Center, Aurora, Colorado, Aurora, CO

Bo Chang Wu    -  Contact Me
University of Colorado Anschutz

Adam Carroll    -  Contact Me
University of Colorado Anschutz

Nicolas Chanes    -  Contact Me
University of Colorado Anschutz

Jessica Rove    -  Contact Me
University of Colorado Anschutz Medical Center and Rocky Mountain Regional VAMC

*Joseph Cleveland    -  Contact Me
University of Colorado Hospital

*Muhammad Aftab    -  Contact Me
University of Colorado, Anschutz Medical Center, Aurora, Colorado

*T. Brett Reece    -  Contact Me
University of Colorado Hospital

Bo Chang Wu    -  Contact Me
University of Colorado Anschutz

Objective: Thoracic endovascular aortic repair (TEVAR) has emerged as the primary therapeutic modality for thoracic aortic aneurysms in eligible candidates. Despite its widespread use, there have been limited reports on TEVAR application in cases involving aortic anomalies. This presentation highlights the successful simultaneous management of descending thoracic aortic aneurysm and right nondominant aortic arch coarctation in a patient with a left dominant double aortic arch anatomy and history of prior open coarctation repair. This was achieved through a combination of TEVAR and vascular plugging.

Case Video Summary: A 56-year-old Caucasian female, who had a history of hypertension, atrial fibrillation post-ablation, and aortic coarctation with left dominant double aortic arch/vascular ring with a remote open coarctation repair, was referred to the Cardiac Surgery Clinic due to asymptomatic aneurysmal dilatation of descending thoracic aorta and coarctation of right aortic arch. A recent echocardiogram showed mild mitral regurgitation and mildly dilated left atrium. She underwent an MR angiogram of the chest, ordered by her cardiologist for surveillance of the repaired aorta according to the guidelines, which reported symmetric aneurysmal dilatation up to 5.1cm at the anastomosis with the proximal descending aorta and distal right aortic arch of 1.3cm. She otherwise had normal cardiac anatomy.
The patient reported feeling well without any symptoms. A CT aortogram showed a double aortic arch with post coarctation dilatation up to 5cm. The right aortic arch gave off the right common carotid and right subclavian arteries, and traveled behind the esophagus, with relative stenosis of 1.2cm prior to joining the anastomosis. The left aortic arch gave off the left common carotid and left subclavian arteries. Given the size of the aneurysm and the coarctation, a TEVAR with vascular plugging was offered to the patient.
We began with a thoracic aortic angiogram. A TEVAR graft was deployed from distal to the left subclavian artery to exclude the aneurysm, followed by an Amplatzer vascular plug deploying to the narrowest portion of the previous coarctation. Postoperative CT angiogram demonstrated successful graft placement with no endoleak. At three years, she remained asymptomatic, doing well, with no degenerative pathology.

Conclusions: The successful utilization of TEVAR with vascular plugging for managing a descending thoracic aortic aneurysm within the context of a double aortic arch introduces a novel, alternative approach to open surgery in patients with such complex aortic anatomies. Considering the patient's asymptomatic presentation, our decision to proceed with TEVAR with concurrent vascular plugging aimed at achieving a comprehensive solution, preemptively preventing tracheal or esophageal compression by occluding the nondominant right aortic arch, and avoiding a redo open surgery. However, long-term follow-up and more cases are needed to further support the extended use of the technique.

Aortic Arch