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Pseudoaneurysm as a Late Complication of Chronic Stanford Type A Intramural Hematoma Requiring Endovascular Repair.

ABSTRACT: Aortic intramural hematoma accounts for 5% to 20% of patients with acute aortic syndrome. Endovascular grafts have evolved as minimally invasive alternatives for treatment in some highly selected patients. We present the case of a patient who had late complications of a chronic Stanford type A intramural hematoma requiring thoracic endovascular aortic repair. (Level of Difficulty: Beginner.).

SUBMITTER: Miller WH

PROVIDER: S-EPMC8305071 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Pseudoaneurysm as a Late Complication of Chronic Stanford Type A Intramural Hematoma Requiring Endovascular Repair.

Miller Wayne H WH Hsi David D Koulova Anna A Vavrenyuk Andrey A George Isaac I Patel Virendra V Takayama Hiroo H

JACC. Case reports 20201216 15

Aortic intramural hematoma accounts for 5% to 20% of patients with acute aortic syndrome. Endovascular grafts have evolved as minimally invasive alternatives for treatment in some highly selected patients. We present the case of a patient who had late complications of a chronic Stanford type A intramural hematoma requiring thoracic endovascular aortic repair. (<b>Level of Difficulty: Beginner.</b>). ...[more]

PMID: 34317196

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Project description:IntroductionThe ExoSeal® (Cordis, Florida, USA) is a bioabsorbable vascular closure device that facilitates hemostasis by deploying a polyglycolic acid (PGA) plug. This report presents the "PseuSeal technique," a novel approach to seal pseudoaneurysm using ExoSeal in an off-label manner.MethodsThe PseuSeal technique includes the PseuSeal Snare and PseuSeal Rendezvous, both performed via a contralateral crossover approach. The choice of approach depends on whether a 4-Fr catheter can be advanced into the pseudoaneurysm cavity. If feasible, the PseuSeal Snare is selected; otherwise, the PseuSeal Rendezvous is employed. In the PseuSeal Snare, a snare is deployed from a 4-Fr catheter within the pseudoaneurysm cavity. An 18-gauge needle is then used to retrogradely puncture the snare loop. A 0.035-inch guidewire is passed through the needle lumen, captured by the snare, and externalized. In the PseuSeal Rendezvous, an 18-gauge needle retrogradely punctures the guidewire within the cavity, and the guidewire is advanced into the needle lumen for externalization. After externalizing the guidewire in both approaches, an ExoSeal-specific sheath is inserted over the guidewire through the pseudoaneurysm neck into the main vessel. A balloon is advanced from the crossover sheath into the main trunk to cover the pseudoaneurysm ostium. The ExoSeal system is then inserted through the second sheath. As the ExoSeal's indicator wire is withdrawn, the balloon is inflated to stabilize the indicator wire, ensuring precise deployment of the PGA plug at the pseudoaneurysm neck. Balloon inflation is maintained for 5 minutes, with an additional 5 minutes if necessary. Hemostasis is confirmed by angiography.ResultsThe PseuSeal technique was successfully applied in five common femoral artery　pseudoaneurysms, all of which had failed ultrasound-guided compression. Each case was treated using a 6-Fr ExoSeal device, with no complications or recurrences observed during follow-up. Case 1 involved an 87-year-old female who developed a pseudoaneurysm following a peripheral intervention. The PseuSeal Snare achieved hemostasis in 32 minutes. Case 2 involved a 60-year-old male presenting with a pseudoaneurysm after a coronary intervention. The PseuSeal Rendezvous achieved hemostasis in 50 minutes.ConclusionThe PseuSeal technique provides an effective alternative for pseudoaneurysm closure.

Project description:Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta. Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling. Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001]. Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.

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Pseudoaneurysm as a Late Complication of Chronic Stanford Type A Intramural Hematoma Requiring Endovascular Repair.

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Pseudoaneurysm as a Late Complication of Chronic Stanford Type A Intramural Hematoma Requiring Endovascular Repair.

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