PMC8423922_01
Timeline of the reported clinical case.
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F1
Diagnostic angiography, computed tomography scans, and 3D printed thoracic aorta model, demonstrating aortic root, and aortic arch pseudoaneurysm (AAP). (A) Computed tomography (CT) angio-study, axial image, showing pre-treatment of AAP. The red line highlights the perfused part of the AAP; the yellow line highlights the thrombosed part. (B) CT angio-study, curved multiplanar reconstruction (MPR) of AAP. (C,D) Volume rendering (VR) reconstructions of ascending aorta. (E,F) 3D print of the thoracic aorta and AAP. (G) Right anterior oblique (RAO) cranial angiographic image of AAP. (H) RAO caudal angiographic image of AAP.
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F2
Contrast-enhanced cardiac CT scans from the patient were post-processed and produced as 3D printed thoracic aorta model of the AAP and aortic root (Figures 2E,F). After balancing the risks and benefits of all approaches (naturally including aortic angiography:Figures 2G,H), we decided to perform, with the patient under local anesthesia and via right brachial artery access (just above the cubital fossa of the elbow) with an eight-French sheath, percutaneous occlusion of the AAP with Amplatzer Septal Occluder 25-mm device (St.
Positioning of the Amplatzer device and the Medtronic valve. (A) Positioning of the Amplatzer device, with angiography demonstrating the apparent total obliteration of the AAP. (B) MPR curved reconstruction of angio-CT, 1 month after placing the Amplatzer device. The red line highlights the perfused part of the AAP; the yellow line highlights the thrombosed part. (C) Severe failure of the native aortic valve, confirmed by angiography. (D) Study of the native aortic valve and confirmation of its severe insufficiency with transesophageal ultrasound. (E) Medtronic valve positioning by accurately locating the position of the annulus. (F) One-year later research for endoleak by transesophageal ultrasound. (G) Maximum intensity projection (MIP) reconstruction of angio-CT after placement of TAVI. The perfused part of the aorta and AAP is highlighted in red. (H) VR reconstructions of the partially thrombosed AAP.
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F3
The device was successfully implanted with the distal disk into the pseudoaneurysm and the proximal disk in the ascending aorta (Figure 3A). After a month of follow-up, CT scan confirmed stabilization of the device but with a small residual flow anterosuperior to the device (4 ml), with incomplete occlusion of the AAP (diameter 5.7 x 2.6 x 4.0 cm, with depressurized volume 21 ml; perfused diameter 2.8 x 1.3 x 2.5 cm, volume 4 ml) (Figure 3B). Minneapolis, MN) after testing the valve in a simulated reconstructed aortic root to ensure that its functional part was not impinged, as both the distal and proximal portions of the Evolut R would be restrained in this 7.5-cm graft. Moreover, both staged procedures were guided by intraoperative transesophageal echocardiography (TEE) (Figures 3C-E). Two days after the procedure, for the onset and persistence of third-degree atrioventricular block, the patient was required to implant a permanent pacemaker (DDDR pacing mode) (Figure 3F).
Embolization of the residual pseudoaneurysm, in volumetric expansion. (A) MPR reconstruction demonstrates continuity between the aortic lumen and the pseudoaneurysm lumen with flow direction highlighted by the red curved arrow. (B) Found the direction of blood flow with selective angiography, after performing CT and during transesophageal ultrasound. (C) Angiography demonstrating the opacification with microcatheter of the residual pseudoaneurysm sac. (D) Controlled release of coils by means of a microcatheter. (E) AAP completely filled with platinum embolization coils, enlaced with poly-lactide-co-glycolide acid (PGLA) fibers. (F) Digital subtraction angiography showing all "metallic" devices. (G) MPR curved reconstruction from angio-CT after placement of coils in the lumen of the AAP. (H) Angio-CT VR reconstructions of the thrombosed pseudoaneurysm with coils.
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F4
An aortography via the right radial artery confirmed the residual sac in AAP, anterosuperior to the Amplatzer (Figure 4B). Using a MP 6-Fr catheter, a microcatheter was placed in the sac, which was confirmed and opacified with radio-opaque contrast agent (Figure 4C). Then, the residual pseudoaneurysm was embolized using six controlled release platinum coils (Concerto Ev3, MRN compatible) (Figures 4D-F). The effective definitive closure of the residual pseudoaneurysmatic sac was confirmed with angiography and, after 1 month, with a CT scan (Figures 4G,H).