Endovascular Repair for Ascending Aortic Graft Side Branch Pseudoaneurysm: A Report of Two Cases

Abstract

Introduction: A pseudoaneurysm arising from the side branch of the prosthesis, following ascending aortic replacement, is extremely rare. Re-intervention usually involves open surgery, replacement of the ascending aorta, or ligation of the side branch. Redo surgery with an additional sternotomy carries the risk of cardiac and vascular injuries, and endovascular treatment can reduce such adverse events.

Report: This study describes the successful thoracic endovascular aortic repair (TEVAR) of two cases of pseudoaneurysms arising from the side branch after ascending aortic replacement. Case 1 involved a 79 year old man who underwent ascending aortic replacement and omentopexy for a ruptured tuberculous aortic aneurysm 13 years ago. The pseudoaneurysm was mushroom shaped with a 30 mm protrusion. Case 2 involved an 83 year old man who underwent ascending aortic replacement for Stanford type A acute aortic dissection 11 years ago. The pseudoaneurysm was rod shaped with a 27 mm protrusion. In both cases, the pseudoaneurysm arising from the side branch was not noted on computed tomography (CT) until one year earlier and was first identified at a routine follow up examination. The pseudoaneurysms required surgical repair because of the risk of rupture; however, TEVAR was selected considering the risks of redo surgery and the patients' ages. It was performed via a femoral artery approach without adverse events using a commercially available thoracic aortic device. Post-operative CT scan showed complete exclusion of the pseudoaneurysm.

Discussion: Although TEVAR is usually not indicated for ascending aortic pathologies, if there is an anatomical indication and a compatible stent graft, TEVAR for the ascending aorta should be the first choice in patients who are inoperable, at high risk and undergoing redo surgery.

Keywords: Ascending aortic replacement; Graft side branch; Pseudoaneurysm; Redo surgery; Thoracic endovascular aortic repair.

Figure 1

(A) Computed tomography after initial ascending aortic replacement and omentopexy. No contrast enhancement in the side branch. (B) There was no pseudoaneurysm formation in the side branch one year previously. (C) Pre-operative three dimensional computed tomography image showing the pseudoaneurysm arising from the side branch (black arrow). (D) Axial image of the pseudoaneurysm (white arrow). (E) Post-operative computed tomography image. (F) There was no endoleak on axial imaging.

Figure 2

(A) No contrast into the side branch after initial surgery. (B) There was no enlargement of the side branch or pseudoaneurysm formation one year previously. (C) Pre-operative computed tomography image showing the pseudoaneurysm (arrow). (D) Presence of contrast into the pseudoaneurysm (white arrow). (E) Post-operative computed tomography image showing stent graft inserted into the ascending aorta. (F) No endoleak seen on axial imaging.