Transcatheter closure of postsurgical aortic pseudoaneurysms guided by three-dimensional image reconstruction: a single-centre experience

Abstract

Background: Postsurgical thoracic aortic pseudoaneurysms (PTAPs) are a potentially lethal complication after cardiac or aortic surgery. Surgical management can pose a challenge with high in-hospital mortality rates. Transcatheter closure is a less-invasive alternative treatment option for selected patients, although current experience is limited.

Aims: We aimed to evaluate procedural and imaging outcomes of our first 11 cases of transcatheter PTAP closure with the use of closure devices.

Methods: Patients with a high operative risk who underwent transcatheter PTAP closure at our centre from 2019 to 2021 were retrospectively included. Suitability was evaluated on preprocedural computed tomography (CT) scans and three-dimensional (3D) reconstructions. All procedures were performed in the catheterisation laboratory. Intraprocedural aortography and postprocedural CT scans with 3D reconstructions were used to evaluate PTAP occlusion.

Results: Eleven consecutive patients with a high operative risk and a history of cardiac/aortic surgery who underwent transcatheter PTAP closure were included. PTAPs were predominantly located at the proximal or distal anastomosis of a supracoronary ascending aortic vascular graft or Bentall prosthesis (82%). Implanted closure devices included Amplatzer Valvular Plug III (82%), Amplatzer septal occluder (9%) and Occlutech atrial septal defect occluder (9%). No periprocedural complications occurred. After device deployment, residual flow was absent on aortography in 64% and minimal residual flow was present in 36% of patients. Subtotal or total occlusion of the PTAP on follow-up CT ranged between 45% and 73%.

Conclusions: Although subtotal or total occlusion of the PTAP was found at follow-up in only 45-73% of cases, transcatheter PTAP closure guided by preprocedural 3D reconstructions can offer a valuable minimally invasive primary treatment option for patients who otherwise would face a high-risk reoperation.

Keywords: Closure device; False aneurysm; Pseudoaneurysm; Three-dimensional reconstruction; Transcatheter closure.

Fig. 1

Infographic

Fig. 2

a–d Aortography before and after device deployment. a Aortography before deployment of an Amplatzer Valvular Plug III (AVP-3) device (case 4), showing flow into the postsurgical thoracic aortic pseudoaneurysm (PTAP). b Aortography after AVP‑3 device deployment (case 4), showing no residual flow into the PTAP. c Aortography before AVP‑3 device deployment (case 2), showing flow into the PTAP. d Aortography after AVP‑3 device deployment (case 2), showing no residual flow into the PTAP

Fig. 3

a–d Pre- and postprocedural 3D reconstructions in case 2. a Preprocedural 3D reconstruction of the thoracic cavity, showing the large postsurgical thoracic aortic pseudoaneurysm (PTAP) located right lateral to the ascending aorta (arrow), at the level of the distal anastomosis of the Bentall prosthesis. b Preprocedural 3D reconstruction of the ascending aorta: intra-aortic view, showing the opening/neck of the PTAP from the ascending aorta. c 3D reconstruction of the ascending aorta: intra-aortic view after placement of the AVP‑3. d 3D reconstruction of the ascending aorta: transverse aortic view after placement of the AVP‑3, showing closure of the PTAP

Fig. 4

a–d Pre- and postprocedural 3D reconstructions in case 5. a Left anterior oblique (LAO) caudal view of 3D reconstruction before plug placement. 1 neck width 10.5 mm. b Right anterior oblique caudal view of 3D reconstruction before plug placement. 1 neck width 3.7 mm. c Preprocedural 3D reconstruction of the thoracic cavity, showing the large postsurgical thoracic aortic pseudoaneurysm (PTAP) (arrow) located at the anterior aortic root, just above the right coronary button. d LAO caudal view of 3D reconstruction after Amplatzer Valvular Plug III placement, revealing incomplete sealing of the PTAP (arrow)