PMC10025951_01
Pre-operative imaging of a 74 year old patient with aortic BCGitis. (A) Positron emission tomography computed tomography (PET/CT) revealed increased uptake on the right border of the visceral abdominal aorta. (B) A non-contrast CT scan showed a 5 cm right latero-aortic heterogeneous mass (arrow) extending to the right edge of the diaphragm, associated with multiple retroperitoneal lymph node formations of less than 1cm. (C) Magnetic resonance imaging confirmed the presence of a rapidly enlarging pararenal aortic pseudoaneurysm (arrow).
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A positron emission tomography/computed tomography (PET/CT) scan revealed a 5 cm right latero-aortic heterogeneous mass extending to the right edge of the diaphragm, with increased uptake on the right border of the visceral abdominal aorta (SUVmax 11) associated with multiple retroperitoneal lymph node formations of less than 1cm and tissue infiltration with a necrotic centre located at the level of the right posterior inframediastinal space (Fig. 1A). Another hypermetabolic focus was found on the right edge of L5 - S1 (SUVmax 7.1), with osteolysis of the upper plate of L4 (Fig. 1B). Magnetic resonance imaging did not show any signs of infectious spondylodiscitis and confirmed the presence of a rapidly expanding pararenal aortic pseudoaneurysm (Fig. 1C).
Intra-operative imaging of endovascular exclusion of aortic BCGitis using a four vessel physician modified device. (A) The aortic graft was unsheathed under sterile conditions on a side table. Fenestrations were created using a cautery pen; a radiographic marker (the single loop portion of an Amplatz Goose Neck Snare kit; Medtronic/Covidien) was sutured around the fenestration with CV5 Gore-Tex ties. (B) CO2 angiography confirmed the presence of a saccular pseudoaneurysm on the lateral aspect of the pararenal aorta (*). (C) Radiography was performed before implantation to confirm marker visibility and orientation. (D) Final CO2 angiography showed patency of all four target vessels and exclusion of the pseudoaneurysm.
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The modification was carried out with a cautery pen and the single loop portion of an Amplatz Goose Neck Snare kit (Medtronic, Minneapolis, MN, USA) sutured around the fenestration with CV5 Gore-Tex ties (Fig. 2A) and silastic laces for re-sheathing. CO2 angiography confirmed the presence of a saccular pseudoaneurysm on the lateral aspect of the pararenal aorta (Fig. 2B). Radiography was performed before implantation to confirm marker visibility and orientation (Fig. 2C).
Post-operative imaging after endovascular exclusion of aortic BCGitis using a four vessel physician modified device. (A) Computed tomography (CT) angiography showed complete exclusion of pseudoaneurysm and patency of all four target vessels on axial slices. (B) 3D reconstruction. (C) Six month positron emission tomography computed tomography (PET/CT) showed persistent uptake at the level of the excluded aneurysm. (D) Twelve month PET/CT showed comparable results.
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Check CT angiography was satisfactory with complete exclusion of the pseudoaneurysm and patency of all four target vessels (Fig. 3A and B). Six and twelve month PET/CT scans showed persistent uptake at the level of the excluded aneurysm (SUVmax 7.5; Fig. 3C and D) and confirmed thrombosis of the aneurysm sac.