Symptomatic Distal Anastomotic Pseudo-aneurysm After the Bentall Procedure Successfully Treated by Supra-aortic Trunk Debranching and Zone 0 Thoracic Endovascular Aneurysm Repair

Abstract

Introduction: Post-operative anastomotic pseudo-aneurysms are rare but potentially lethal complications after the Bentall procedure. When symptomatic or ruptured, expedited repair is warranted, and open surgery may carry significant bleeding risk, particularly when these lesions project anteriorly. As totally endovascular techniques are frequently limited owing to hostile anatomies, complex hybrid interventions are an alternative option in such scenarios. Report: A 53 year old man with a previous Bentall procedure performed 10 years previously for DeBakey type 1 dissection was admitted with chest pain. Computed tomography angiography revealed a distal anastomotic pseudo-aneurysm. Percutaneous pseudo-aneurysm occlusion with a septal occluder plug was performed initially, with significant clinical improvement but without total sac thrombosis. The patient was discharged under strict surveillance, but six months later was re-admitted owing to hoarseness and new onset of chest pain. As the patient developed acute pain and compressive symptoms, urgent treatment was required. As the pseudoaneurysm projected anteriorly into the posterior aspect of sternum, significantly bleeding risk was anticipated with redo sternotomy. A hybrid repair was then planned, with a full supra-aortic trunk debranching (carotide carotid and left carotidesubclavian bypass) and zone 0 TEVAR with a single parallel graft to the brachiocephalic trunk. The patient was discharged 10 days later. Total aneurysm exclusion was achieved, with no complications reported after six months follow up. Discussion: Hybrid procedures may represent a safe and feasible alternative to open surgery in symptomatic ascending aortic pseudo-aneurysms. However, long term follow up studies are required to confirm the durability of these procedures.

Right Coronary Artery Button Pseudoaneurysm After the Modified Bentall Procedure

“…Pseudoaneurysms have been reported four months to 17 years after the index procedure [1,[4][5][6][7][9][10][11][12]. In our patient, right coronary button dehiscence presented in the early postoperative phase.…”

Ascending aorta thoracic endovascular aortic repair for infected pseudoaneurysm

“…Hybrid debranching-TEVAR procedures and endovascular coiling have been reported. 14,15 However, endovascular coiling or plugging would likely fail to embolize the high-flow pseudoaneurysm in this patient. Patient and device selection are of paramount importance in AA-TEVAR to avoid complications such as stroke or myocardial infarction.…”

Abdominal Stent-Graft Treatment of Ascending Aortic Pseudoaneurysm Following Transcatheter Aortic Valve Implantation

“…As mentioned, the short distance between the pseudoaneurysm entry tear and the IA branch-off presented a challenge for SG selection. Several techniques have been described for ascending aortic pathologies with landing zones too short to deploy a conventional SG, including fenestrated TEVAR [ 21 ], IA debranching and Ishimaru zone 0 TEVAR with a single chimney to the IA [ 3 ], closing the pseudoaneurysm using an Amplatz Type II or Type III vascular plug (AVP) only, or first coil embolizing the pseudoaneurysm followed by AVP insertion [ 22 ], and even a novel Endo-Bentall procedure [ 23 ]. In our case, the short landing zone challenge was overcome by selecting an off-the-shelf SG of the appropriate dimensions and by careful deployment preplanning to ensure continued patency of the IA.…”

“…Such clinical scenarios are primarily treated by a re-do surgical procedure, predominately due to the fact that surgical treatment offers the best short- and long term survival rates. However, large retrosternal pseudoaneurysms, which are prone to rupture upon chest exploration, may favor minimally invasive approaches [ 2 , 3 ]. A prior valve-in-valve (ViV) TAVI presents an additional scarcely researched variable in patients with retrosternal ascending aortic pseudoaneurysms.…”