P099. Development and Management of Aortic Pseudoaneurysm after Stenting for Aortic Coarctation
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
University of Colorado Anschutz
Fort Collins, CO
United States - Contact Me
Ananya Shah is a current medical student at the University of Colorado School of Medicine. She graduated with a bachelor of science in psychology from the University of Colorado Denver. She is currently a part of the Research Track Program and has been involved in research in the cardiology and cardiothoracic surgery departments for several years. She is an active member of the Aortic Surgery Research Laboratory in the Department of Cardiothoracic Surgery at the University of Colorado.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objective
Severe coarctation of the aorta can be challenging to treat. Intravascular stent graft therapy is a well-established therapeutic option; however, proper positioning and shape of the graft is critical. We describe the case of a pediatric patient who likely developed a pseudoaneurysm, requiring re-operation, due to the angulation created by the initial stent graft.
Methods:
We discuss the case of a 14-year-old male who was found to have a near complete interruption of his aorta at the site of a coarctation involving the distal transverse arch and descending thoracic aorta. The patient previously had a stent graft placed across this interruption, but the placement of the graft created an angulation with the patient's distal arch. The patient developed bacteremia and was found to have developed a multilobular pseudoaneurysm proximal to the previously placed stent graft.
Results:
The patient described above was taken to the OR for resection of the infected stent graft, resection of the pseudoaneurysm, and interposition graft repair of the coarctation. The pseudoaneurysm may have developed due to the graft causing erosion into the aorta or due to the angulation created between the graft and the patient's distal arch leading to stasis of blood flow; however, both are the result of the stent graft not being congruent with the patient's coarctation anatomy. Due to the complication, a higher risk procedure needed to be performed, and a distal arch replacement was required. Intraoperatively, the patient was found to have severe inflammation around the stent graft that also involved the vagus nerve and the recurrent laryngeal nerve. The aorta was opened, and the inflammatory tissue, pseudoaneurysmal tissue, and stent graft were removed. An 18mm antibiotic-soaked dacryon graft, was then sized and inserted. An anastomosis of this graft was carried out to the proximal aorta with a small incision created up onto the left carotid artery to enlarge the anastomosis to treat the hypoplastic transverse arch. Enlarging the anastomosis helped ensure that the new graft would create less of an angulation with the transverse arch, thereby decreasing the potential for static blood flow to prevent development of another pseudoaneurysm. Next, the subclavian artery was anastomosed onto the graft, completing the reconstruction. Post-procedure echo demonstrated a mildly increased velocity of 2.1 m/s at anastomosis, proximal to the left common carotid, with otherwise normal aortic flow pattern and normal left ventricular (LV) systolic function. The patient's post-operative course was otherwise uncomplicated, and the patient was discharged with oral antibiotics on hospital day 12 at baseline neurologic status.
Conclusion:
For patients with distal aortic arch coarctation, consideration of aortic shape and angulation is critical in treatment, given the potential for disruptions in laminar flow. Although managed successfully in this case report, therapies such as thoracic branched endografts or more novel technologies suited for the transition from the arch to the descending aorta, should be considered. These therapies may provide more coverage and create a better landing zone, thus reducing angulation and optimizing blood flow.
Authors
Adam Carroll (1), Ananya Shah (1), Muhammad Aftab (1), James Jaggers (2), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO, (2) Children's Hospital Colorado, Aurora, CO
Severe coarctation of the aorta can be challenging to treat. Intravascular stent graft therapy is a well-established therapeutic option; however, proper positioning and shape of the graft is critical. We describe the case of a pediatric patient who likely developed a pseudoaneurysm, requiring re-operation, due to the angulation created by the initial stent graft.
Methods:
We discuss the case of a 14-year-old male who was found to have a near complete interruption of his aorta at the site of a coarctation involving the distal transverse arch and descending thoracic aorta. The patient previously had a stent graft placed across this interruption, but the placement of the graft created an angulation with the patient's distal arch. The patient developed bacteremia and was found to have developed a multilobular pseudoaneurysm proximal to the previously placed stent graft.
Results:
The patient described above was taken to the OR for resection of the infected stent graft, resection of the pseudoaneurysm, and interposition graft repair of the coarctation. The pseudoaneurysm may have developed due to the graft causing erosion into the aorta or due to the angulation created between the graft and the patient's distal arch leading to stasis of blood flow; however, both are the result of the stent graft not being congruent with the patient's coarctation anatomy. Due to the complication, a higher risk procedure needed to be performed, and a distal arch replacement was required. Intraoperatively, the patient was found to have severe inflammation around the stent graft that also involved the vagus nerve and the recurrent laryngeal nerve. The aorta was opened, and the inflammatory tissue, pseudoaneurysmal tissue, and stent graft were removed. An 18mm antibiotic-soaked dacryon graft, was then sized and inserted. An anastomosis of this graft was carried out to the proximal aorta with a small incision created up onto the left carotid artery to enlarge the anastomosis to treat the hypoplastic transverse arch. Enlarging the anastomosis helped ensure that the new graft would create less of an angulation with the transverse arch, thereby decreasing the potential for static blood flow to prevent development of another pseudoaneurysm. Next, the subclavian artery was anastomosed onto the graft, completing the reconstruction. Post-procedure echo demonstrated a mildly increased velocity of 2.1 m/s at anastomosis, proximal to the left common carotid, with otherwise normal aortic flow pattern and normal left ventricular (LV) systolic function. The patient's post-operative course was otherwise uncomplicated, and the patient was discharged with oral antibiotics on hospital day 12 at baseline neurologic status.
Conclusion:
For patients with distal aortic arch coarctation, consideration of aortic shape and angulation is critical in treatment, given the potential for disruptions in laminar flow. Although managed successfully in this case report, therapies such as thoracic branched endografts or more novel technologies suited for the transition from the arch to the descending aorta, should be considered. These therapies may provide more coverage and create a better landing zone, thus reducing angulation and optimizing blood flow.
Authors
Adam Carroll (1), Ananya Shah (1), Muhammad Aftab (1), James Jaggers (2), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO, (2) Children's Hospital Colorado, Aurora, CO
Presentation Duration
PODS will be on display in the exhibit hall for the duration of the meeting during exhibit hall hours. PODS will also be available for viewing on the meeting website. There is no formal presentation associated with your POD, but we encourage you to visit the PODS area during breaks to connect with those viewing.