Aortic rupture during transcatheter aortic valve replacement requiring emergent thoracic endovascular aortic repair and endograft infection requiring endograft explant

Abstract

Infection of endografts after thoracic endovascular aortic repair (TEVAR) is a catastrophic complication with dramatically high morbidity and mortality. We present the case of a 58-year-old gentleman who underwent TEVAR for aortic rupture during transcatheter aortic valve replacement, later presenting with TEVAR infection, endocarditis, and aortobronchial fistula who underwent TEVAR explantation, aortic valve replacement, and aortic reconstruction. The patient consented to publication of his operative course.

Keywords: Aortobronchial; Explant; Fistula; Infection; TEVAR.

Fig 1

Intraoperative angiogram at index procedure before thoracic endovascular aortic repair (TEVAR) placement. Maldeployed Sapien 3 ultra valve was pulled back into descending thoracic aorta, and additional valve was adequately placed. Periaortic contrast (yellow arrow) is seen around the distal valve with concern for contained aortic rupture in the setting of intraoperative hemodynamic instability.

Fig 2

Patient presentation to emergency department following development of hemoptysis. (A) Axial cross-section demonstrating severe aortic wall thickening in the proximity of the left mainstem bronchus (asterisk). (B) Coronal view with concern for poor distal seal and possible endograft migration (yellow arrow).

Fig 3

Postoperative imaging obtained 3 weeks after staged endograft and transcatheter aortic valve replacement (TAVR) explantation with extra-anatomic reconstruction. (A) Course of the patent bypass graft from the ascending aortic graft tunneled through the diaphragm to the supraceliac aorta. (B) A portion of excluded remnant aorta can be seen (marked with asterisk) with associated wall thickening is shown. (C and D) A three-dimensional reconstruction of the patient's final anatomy is presented.