JACC: CARDIOVASCULAR INTERVENTIONS ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
VOL. 7, NO. 3, 2014 ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2013.07.017
IMAGES IN INTERVENTION
Percutaneous Treatment of a Complex Saccular Aortic Pseudoaneurysm With Covered Stenting After Subclavian Artery Translocation Cecilia Craviari,* Nathaniel W. Taggart, MD,* Frank Cetta, MD,*y Donald J. Hagler, MD,*y Thomas C. Bower, MD,z Daniel A. Mauriello, MD,* Jonathan N. Johnson, MD* Rochester, Minnesota
A 44-year-old woman presented to our institution for evaluation of an expanding aortic saccular pseudoaneurysm. She had a history of an end-end repair of coarctation of the aorta at 4 years of age. At 29 years of age, she received a diagnosis of a pseudoaneurysm measuring 10 mm at the site of the previous repair. Since that time, the pseudoaneurysm had doubled in size. She also had a history of hypertension and had been treated with atenolol. At time of our evaluation, computed tomography angiography was performed, demonstrating mild narrowing of the aorta just distal to the origin of the left subclavian artery with a minimal diameter of 16 mm (Fig. 1). The pseudoaneurysm measured 21 17 20 mm. Due to the location of the pseudoaneurysm just distal to the origin of the left subclavian artery, the vascular surgery team translocated the left subclavian artery to the left carotid artery. Two months later, with approval from the U.S. Food and Drug Administration for compassionate use, she underwent placement of a 20-mm 3.4-cm covered stent (Cheatham-Platinum [CP] stent, NuMED, Hopkinton, New York) to dilate the coarctation and simultaneously cover the saccular pseudoaneurysm. The stent was pre-mounted on a 20mm balloon-in-balloon (BIB) catheter. Postprocedure DynaCT rotational angiography (Siemens, Erlangen, Germany) demonstrated a
7-mm residual neck not covered by the stent (Fig. 2). The patient returned for additional placement of 2 CP stents (3.4 and 2.8 cm) placed over a 20-mm BIB catheter covering the orifice of the pseudoaneurysm. Post-procedure, there was no evidence of residual aneurysm filling or dissection on DynaCT imaging, and
Figure 1. Computed Tomography Angiography With 3-Dimensional Reconstruction From the *Department of Pediatrics/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; yDepartment of Medicine/Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; and the zDepartment of Surgery/Division of Vascular Surgery, Mayo Clinic, Rochester, Minnesota. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received July 1, 2013; accepted July 3, 2013.
Computed tomography angiography with 3-dimensional reconstruction showing the saccular aortic pseudoaneurysm (arrows) from the anterior (top left), lateral (top middle), and posterior (top right) aspects. (Bottom) Demonstration of the relationship of the pseudoaneurysm (*) to the pulmonary arterial tree and the takeoff of the left subclavian artery.
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Craviari et al. Covered Stenting to Treat Saccular Aortic Pseudoaneurysm
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 7, NO. 3, 2014 MARCH 2014:e23–4
the patient tolerated the procedure well (Fig. 3). Followup 12 months later revealed an excellent result with no residual pseudoaneurysm and no residual gradient. Reprint requests and correspondence: Dr. Jonathan N. Johnson, Pediatric Cardiology, Mayo Clinic, Gonda 6-138SW, 200 First Street SW, Rochester, Minnesota 55905. E-mail: johnson. [email protected].
Key Words: aortic pseudoaneurysm - cardiac CT coarctation of the aorta - covered stenting pseudoaneurysm.
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Figure 2. Residual Pseudoaneurysm After Initial Stent Placement DynaCT rotational angiography with 3-dimensional reconstruction was performed after initial covered stent placement. The residual pseudoaneurysm is noted (*), filling with contrast despite the stent. Alternate imaging planes demonstrated a 7-mm residual neck not covered by the stent. The transposed left subclavian artery is seen arising from the left carotid artery, with the stump of the original left subclavian origin also filling with contrast.
Figure 3. Successful Result After Additional Stent Placement DynaCT rotational angiography with 3-dimensional reconstruction was performed after placement of 2 additional covered stents. No residual pseudoaneurysm filling is seen. The transposed left subclavian artery can be seen arising from the left carotid artery (SC), whereas the left subclavian stump has been covered by the proximal stent.
VOL. 7, NO. 3, 2014 ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2013.07.017
IMAGES IN INTERVENTION
Percutaneous Treatment of a Complex Saccular Aortic Pseudoaneurysm With Covered Stenting After Subclavian Artery Translocation Cecilia Craviari,* Nathaniel W. Taggart, MD,* Frank Cetta, MD,*y Donald J. Hagler, MD,*y Thomas C. Bower, MD,z Daniel A. Mauriello, MD,* Jonathan N. Johnson, MD* Rochester, Minnesota
A 44-year-old woman presented to our institution for evaluation of an expanding aortic saccular pseudoaneurysm. She had a history of an end-end repair of coarctation of the aorta at 4 years of age. At 29 years of age, she received a diagnosis of a pseudoaneurysm measuring 10 mm at the site of the previous repair. Since that time, the pseudoaneurysm had doubled in size. She also had a history of hypertension and had been treated with atenolol. At time of our evaluation, computed tomography angiography was performed, demonstrating mild narrowing of the aorta just distal to the origin of the left subclavian artery with a minimal diameter of 16 mm (Fig. 1). The pseudoaneurysm measured 21 17 20 mm. Due to the location of the pseudoaneurysm just distal to the origin of the left subclavian artery, the vascular surgery team translocated the left subclavian artery to the left carotid artery. Two months later, with approval from the U.S. Food and Drug Administration for compassionate use, she underwent placement of a 20-mm 3.4-cm covered stent (Cheatham-Platinum [CP] stent, NuMED, Hopkinton, New York) to dilate the coarctation and simultaneously cover the saccular pseudoaneurysm. The stent was pre-mounted on a 20mm balloon-in-balloon (BIB) catheter. Postprocedure DynaCT rotational angiography (Siemens, Erlangen, Germany) demonstrated a
7-mm residual neck not covered by the stent (Fig. 2). The patient returned for additional placement of 2 CP stents (3.4 and 2.8 cm) placed over a 20-mm BIB catheter covering the orifice of the pseudoaneurysm. Post-procedure, there was no evidence of residual aneurysm filling or dissection on DynaCT imaging, and
Figure 1. Computed Tomography Angiography With 3-Dimensional Reconstruction From the *Department of Pediatrics/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota; yDepartment of Medicine/Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; and the zDepartment of Surgery/Division of Vascular Surgery, Mayo Clinic, Rochester, Minnesota. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received July 1, 2013; accepted July 3, 2013.
Computed tomography angiography with 3-dimensional reconstruction showing the saccular aortic pseudoaneurysm (arrows) from the anterior (top left), lateral (top middle), and posterior (top right) aspects. (Bottom) Demonstration of the relationship of the pseudoaneurysm (*) to the pulmonary arterial tree and the takeoff of the left subclavian artery.
e24
Craviari et al. Covered Stenting to Treat Saccular Aortic Pseudoaneurysm
JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 7, NO. 3, 2014 MARCH 2014:e23–4
the patient tolerated the procedure well (Fig. 3). Followup 12 months later revealed an excellent result with no residual pseudoaneurysm and no residual gradient. Reprint requests and correspondence: Dr. Jonathan N. Johnson, Pediatric Cardiology, Mayo Clinic, Gonda 6-138SW, 200 First Street SW, Rochester, Minnesota 55905. E-mail: johnson. [email protected].
Key Words: aortic pseudoaneurysm - cardiac CT coarctation of the aorta - covered stenting pseudoaneurysm.
-
Figure 2. Residual Pseudoaneurysm After Initial Stent Placement DynaCT rotational angiography with 3-dimensional reconstruction was performed after initial covered stent placement. The residual pseudoaneurysm is noted (*), filling with contrast despite the stent. Alternate imaging planes demonstrated a 7-mm residual neck not covered by the stent. The transposed left subclavian artery is seen arising from the left carotid artery, with the stump of the original left subclavian origin also filling with contrast.
Figure 3. Successful Result After Additional Stent Placement DynaCT rotational angiography with 3-dimensional reconstruction was performed after placement of 2 additional covered stents. No residual pseudoaneurysm filling is seen. The transposed left subclavian artery can be seen arising from the left carotid artery (SC), whereas the left subclavian stump has been covered by the proximal stent.
