Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device—Case series of six patients

Percutaneous Closure of Aortic Pseudoaneurysm byAmplatzer Occluder Device—Case Series of Six Patients

Jamal Hussain,* MD, Robert Strumpf, MD, Grayson Wheatley, MD, and Edward Diethrich, MD

Thoracic pseudoaneurysms are rare variety of aortic disorders. Although mostlyasymptomatic, they represent potentially fatal conditions (Sullivan et al., Chest1988;93:138–143; Razzouk et al., Ann Surg 1993;59:818–823) that are traditionallytreated surgically. False aneurysms of aorta are usually a late complication of previoussurgical procedure (Sullivan et al., 1988)-especially reconstructive surgery, trauma(Razzouk et al., 1993), and rarely infection (Sanchez-Recalde et al., J Am Coll Cardiol2003;41:152–154). Surgical management is often complicated by poor outcomes withhigh morbidity and mortality (Mulder et al., Arch Surg 1998;133:45–49). Endovasculartreatment is emerging as promising options for aortic diseases with fewer complica-tions. We report a series of six cases at a single center where Amplatzer devise wasused to treat thoracic aortic pseudo aneurysm. To our knowledge only one series ofthree cases (Kanani et al., Catheter Cardiovasc Interv 2007;69:146–153) and few casereports (Bashi et al., Catheter Cardiovasc Interv 2005;65:547–551) of successful closurehave been published previously. Our case series is the largest, so far, including mortal-ity and specifically the preprocedural and postprocedural CT angiographic assessmentof the pseudoaneurysms. ' 2009 Wiley-Liss, Inc.

Key words: aortic pseudoaneurysm; Amplatzer occluder device; endovascular

INTRODUCTION

Thoracic pseudoaneurysms are a rare variety of aor-tic disorders. Although mostly asymptomatic, they rep-resent potentially fatal conditions [1,2] that are tradi-tionally treated surgically. False aneurysms of aorta areusually a late complication of previous surgical proce-dure [1], especially reconstructive surgery, trauma [2],and rarely infection [3].Surgical management is often complicated by poor

outcomes with high morbidity and mortality [4]. Endo-vascular treatment is emerging as a promising optionfor aortic diseases with fewer complications. Experi-ence is limited in treating aortic pseudoaneurysms withtranscatheter techniques. Case reports have been pub-lished with thrombin injection [5], coiling [6], andendovascular stents [7]. Few case reports have beenpublished regarding the use of Amplatzer occluder de-vice [8,9] in the treatment of aortic pseudoaneurysms.Although technically challenging, this novel techniqueis a feasible alternative with fewer potential complica-tions. There are two types of Amplatzer devices,Amplatzer septal occluder and Amplatzer Cribriform.Amplatzer septal occluder is a self-expandable, doubledisc device made from Nitinol wire mesh. The twodiscs are linked together by a short connecting waistcorresponding to the size of the atrial septal defect. Thediscs and the waist are filled with polyester fabric. TheCribriform device is made of the same material; how-

ever, the connecting waist is narrow. This is used formultifenestrated atrial septal defects (Fig. 1A and B).We report a series of six cases at a single center

where Amplatzer device was used to treat thoracic aor-tic pseudoaneurysm. To our knowledge, only one se-ries of three cases [8] and few case reports [9] of suc-cessful closure have been published previously. Ourcase series is the largest thus far including a mortalityand specifically the preprocedural and postproceduralCT angiographic assessment of the pseudoaneurysms.

PROCEDURAL TECHNIQUE

Similar technique with some variation was used inall cases. Initial access was obtained through the femo-

Conflict of interest: Nothing to report.

Cardiac Catheterization Laboratories, Arizona Heart Hospital,Arizona Heart Institute, Phoenix, Arizona

*Correspondence to: Jamal Hussain, MD, Arizona Heart Hospital,

1930 East Thomas Road, Phoenix, AZ 85006.

E-mail: [email protected]

Received 6 September 2008; Revision accepted 14 September 2008

DOI 10.1002/ccd.21833

Published online 9 January 2009 in Wiley InterScience (www.

interscience.wiley.com).

' 2009 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 73:521–529 (2009)

ral artery. Aortic angiogram was performed with a pig-tail catheter. Then, diagnostic coronary catheter (usu-ally a right Judkin or multipurpose catheter) over a0.035 inches wire (Supracore wire, J-tip wire or glidewire) was used to engage the pseudoaneurysm and per-form selective angiogram of the pseudoaneurysm. Insome cases, intravascular ultrasound (IVUS) was per-formed to assess the size of the neck of the pseudoan-eurysm. Then Amplatzer delivery sheath was passedinto the aorta with its tip in the pseudoaneurysm.Amplatzer device was selected based on the size ofthe neck. For larger necks, Amplatzer atrial leveloccluder was used, and for narrow neck AmplatzerCribriform device was used. After deploying the de-vice, final aortic angiogram was performed. Procedureswere performed under general anesthesia.

Case 1

The patient was a 58-year-old male who previouslyhad open repair of the ascending aortic aneurysm witha graft. At that time patient had a series of smallstrokes from which he recovered. CT scan and fluoro-scopic angiography revealed aortic pseudoaneurysm(Fig. 2A–C). Similar steps as described earlier werefollowed. An Amplatzer cribriform occluder size18 mm was deployed across the neck of the pseudo-

aneurysm. Postprocedure angiogram and CT scan areshown in Fig. 3A and B.

Case 2

The patient was a 79-year-old woman with recentlydiagnosed ascending aortic pseudoaneurysm. During anevaluation for elective knee surgery, a chest X-raydemonstrated abnormality in the mediastinum. Heronly recollection of chest trauma occurred �16 yearsago when she fell off a ladder. She underwent furtherevaluation with a CT scan and cardiac catheterization,which demonstrated pseudoaneurysm (Fig. 4) immedi-ately superior to sinotubular junction. The procedurewas performed under general anesthesia, under fluoro-scopic guidance via femoral approach. The Amplatzerseptal occluder was deployed. Angiographic picturesrevealed minor leak, which is expected to disappearonce the device gets thrombosed and endothelialized(Fig. 5). Subsequent CT scan (Fig. 6A and B) revealedoccluded pseudoaneurysm.

Case 3

The patient was a 78-year-old female with history ofbioprosthetic aortic valve and previous repair of Stan-ford Type A aortic dissection in 2001 presented withintermittent chest pain. She had a CT of the chest that

Fig. 1. (A) Amplatzer Septal occluder for ASD closure. (B) Amplatzer Cribriform occluder formultifenestrated ASD. [Color figure can be viewed in the online issue, which is available atwww.interscience.wiley.com.]

522 Hussain et al.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

revealed aortic pseudoaneurysm measuring 4.5 cm 35.1 cm at the transverse aortic level (Fig. 7). As a partof work up for the intermittent nature of her symptomsshe also had esophageogastroduedenoscopy, which wasreported as probable extrinsic compression of the prox-imal esophagus. She was evaluated by cardiothoracicsurgery service and percutaneous closure of the pseu-

doaneurysm was recommended. Open retrocannulationof the left axilliary artery was performed, and arterio-gram of the descending thoracic aorta was performed(Fig. 8A and B). IVUS of the descending thoracicaorta was performed. The pseudoaneurysm was sizedwith a 34-mm Amplatzer sizing balloon. Then a 26-mm septal occluder was deployed. Postprocedure

Fig. 2. (A) Three-dimensional CT view of pseudoaneurysm with a narrow neck. (B) CT angio-gram. (C) Angiography of pseudoaneurysm. [Color figure can be viewed in the online issue,which is available at www.interscience.wiley.com.]

Percutaneous Closure of Aortic Pseudoaneurysm 523


angiogram revealed the Amplatzer device to be in thelumen of aorta rather than the pseudoaneurysm (Fig.9); it was confirmed by CT scan. Again retrocannula-tion of the right femoral artery and left axilliary arterywas performed and attempts were made to retrieve the

device, but were unsuccessful. The patient became hy-potensive. Open sternotomy was performed and herchest was full of blood. Cardiopulmonary resuscitationwas initiated. However, she could not be resuscitatedand finally died.

Fig. 3. Post-Amplatzer deployment (A). Three-dimensional view of pseudoaneurysm. (B) CTangiogram. Fluoroscopic angiogram. [Color figure can be viewed in the online issue, which isavailable at www.interscience.wiley.com.]

Fig. 4. Angiography of pseudoaneurysm of the ascendingaorta.

Fig. 5. Angiography post-Amplatzer deployment with minorleak.

524 Hussain et al.


Case 4

The patient was a 60-year-old lady with history ofaortic arch and descending thoracic aorta replace-ment. She had been having back pain for the past 8months. She was evaluated and found to have a mid-descending thoracic aortic ulcer. Her thoracic aortawas ectatic so no suitable landing zone was foundfor an endoluminal graft. Therefore, she was eval-uated and felt to be a candidate for percutaeous clo-sure of the mid-thoracic aortic aneurysm. Afterobtaining arterial access descending, thoracic aorto-gram (Fig. 10) was performed, which revealed ectaticthoracic aorta and penetrating ulcer with pseudoaneu-rysm in the middle. After confirming the positionangiographically, we deployed a Cribriform occluder35 mm device to the lesion. Final angiographic pic-ture revealed a good seal and minimal leak into thecavity (Fig. 11), which is usually expected to disap-pear once the device thrombose and endothelialize.

Subsequently, the patient was discharged in stablecondition.

Case 5

The patient was a 75-year-old male with a historyof atrial fibrillation, mitral valve endocarditis, and mi-tral valve replacement with St. Jude valve in 2004. Hispostoperative course was complicated by sternal wounddehiscence and infection requiring debridement andredo sternotomy. He continued to have fever and wasfound to have mitral prosthetic valve endocarditis andhad a redo mitral valve replacement with Medtronic

Fig. 6. Post deployment (A); three-dimensional view (B);transverse view (C). [Color figure can be viewed in the onlineissue, which is available at www.interscience.wiley.com.]

Fig. 7. (A) Three-dimensional view of the pseudoaneurysm ofthe aortic arch. (B) Transverse CT angiographic view of thepseudoaneurysm depicting the connection or neck of thepseudoaneurysm. [Color figure can be viewed in the onlineissue, which is available at www.interscience.wiley.com.]



mosaic porcine valve via right thoracotomy in January2005. He underwent a CT scan of the chest in May2005, which demonstrated a small mass of his ascend-ing aorta that was not interpreted as an aneurysm. Sub-sequently in November 2005, he had a chest X-raythat revealed large ascending aortic aneurysm not pre-viously seen by CT scan. This was felt to be at theprevious cardioplegia site or the deairing needle site.The patient was referred to us for possible stenting ofhis pseudoaneurysm. A repeat CT scan revealed an

irregular shaped mass anterior to aorta measuring7.6 cm 3 8 cm. The neck appeared to be 6–7 mmwide. Similar technique as described earlier was fol-lowed. Preprocedure angiogram revealed a pseudoaneu-rysm of the ascending aorta (Fig. 12). An 18-mmAmplatzer septal occluder device was deployed. Post-deployment angiogram (Fig. 13) revealed minor leakexpected to resolve once the device gets thrombosedand endothelialized. Post deployment CT scan isshown in Fig. 14.

Fig. 8. (A and B) Preclosure angiogram showing the pseudoaneurysm on the inferior aspectof the transverse aorta.

Fig. 9. Amplatzer device in the middle of the transverse aorta instead of across the neck ofthe pseudoaneurysm. Percutaneous attempts at retrieval were unsuccessful. (A) CT scan; (B)aortogram.

526 Hussain et al.


Case 6

The patient was an 81-year-old man with recentlydiscovered focal pseudoaneurysm of the ascendingaorta. His medical history was significant for hyperten-sion and atrial fibrillation. There was no history of

trauma. Options of further management were discussedwith the patient and it was decided to close the pseu-doaneurysm percutaneously with Amplatzer occluderdevice. Procedure methodology was similar to previ-ously described method in this article. After perform-

ing ascending aortic angiography, two large aortic

pseudoaneurysms were identified (Fig. 15). After enter-

ing the larger sac with angled glide wire, IVUS was

done with Volcano probe which demonstrated eccentric

neck of 16 mm (Fig. 16). The sac was entered with 10

Fig. 10. Angiogram of pseudoaneurysm via Amplatzer deliv-ery sheath.

Fig. 11. Amplatzer device excluding pseudoaneurysm.

Fig. 12. Angiogram of pseudoaneurysm preclosure.

Fig. 13. Post-Amplatzer device deployment angiogram withminor leak into pseudoaneurysm.



French Amplatzer delivery sheath, attempts were made

to occlude the origin of pseudoaneurysm using

Amplatzer atrial level occluder devices 18, 22, 28 mm.However, all devices were of insufficient size and con-figuration, and occluder would slip out of the pseudo-aneurysm. The procedure was stopped. The patientlater had open repair.

DISCUSSION

Conventional treatment for aortic pseudoaneurysm issurgical ligation and in some cases replacement with agraft. Surgery has variable outcomes. In addition to the

surgical morbidity, mortality still remains a concern[10]. With emerging endovascular techniques for otherdisorders of aorta, different endovascular treatmentmodalities such as coil embolization, stent-graft place-ment, and thrombin injection have been used to treataortic pseudoaneurysms. However, depending on thelocation of pseudoaneurysm and the size of the necksome of these techniques may have limitation. Stentgraft may not be an option in case with inadequatelanding zone and in proximity to the supra-aortic ves-sels. Coil embolization has been reported to treat nar-row neck pseudoaneurysms [6]. Thrombin injection hasbeen utilized [5], however, its utility may be limitedwith wide-neck pseudoaneurysms and in proximity tothe origin of the great vessels.

Fig. 14. CT scan images of Amplatzer excluding pseudoaneu-rysm. (A) Saggital view; (B) transverse view.

Fig. 15. (A and B) Selective angiogram of pseudoaneurysmsof ascending aorta.

528 Hussain et al.


Amplatzer occluder devices may have broader usein the treatment of aortic pseudoaneurysms. Thesedevices are available in different sizes and can be usedin some large neck pseudoaneurysms. Proximity to thesupraaortic vessel does not seem to be an issue. Mostof these are detected as part of work up or incidentallyon X-ray or CT scan. Newer high-resolution CT scanprovides accurate description of the pseudoaneurysmand a noninvasive modality to follow up these patientspostoperatively.Assessment of the size of the entry point of pseudo-

aneurysm can be done with IVUS. Selection of the de-vice can be tailored to the size of the neck. Amplatzerdevices may not be an option in some cases withbroad neck, as in one of our cases. These pseudoaneur-ysms may best be treated surgically or with stent graft.Also, if assessment of the size of entry point is diffi-cult or the device slips out of the sac, deploymentshould be avoided as it may lead to mal-deployment inthe aorta with disastrous outcome.Our follow up is limited in terms of recurrence or

persistent leaks. Recurrence has been reported withanastomotic pseudoaneurysm treated with coil emboli-zation.

ACKNOWLEDGMENTS

The authors thank Yvonne Smith, graphic artist, forher assistance with preparation of the manuscript images.

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Fig. 16. Intravascular ultrasound images of the ascending aorta. Dissection flap is probablyat the entrance point of the pseudoaneurysm.



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Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device—Case series of six patients