PMC9871350_01
Chest CT with transverse view showing the pseudoaneurysm (asterisk) in the ascending aorta with surrounding soft tissue thickening (arrow). Asc Ao, Ascending aorta.
gr1.jpg
PMC9871350_01_gr1.jpg
fig1
However, around 8 months after the initial diagnosis, the surveillance scan suggested an increase in the pseudoaneurysm size associated with surrounding soft tissue thickening and sternal osteomyelitis (Figure 1). By TEE, the pseudoaneurysm had a neck of 7 x 8 mm and the sac measured 31 x 26 x 18 mm, with a partially thrombosed cavity (Figure 4, Video 1).
Chest CT with (A) curved planar reformat reconstruction of the RIMA graft and (B) transverse view showing the close proximity of the graft (arrow) to the pseudoaneurysm (asterisk) and the sternum. Asc Ao, Ascending aorta; RIMA, right internal mammary artery graft.
gr2.jpg
PMC9871350_01_gr2.jpg
fig2
One critical factor was the presence of an in situ right internal mammary artery graft to the left anterior descending artery, with the graft coursing anterior to the aorta, adjacent to the pseudoaneurysm and just underneath the sternum (Figure 2); therefore, an open approach would carry a high risk of graft injury. II, which has 12 mm disks, was placed at the neck of the pseudoaneurysm (Figure 6, Videos 2 and 3). Initial placement appeared adequate angiographically, but TEE highlighted that a portion of the aortic disk may have been deployed into the pseudoaneurysm neck (Video 4), prompting us to reposition the device and deploy once properly placed.
Aortic digital subtraction angiography in left anterior oblique view showing the pseudoaneurysm (asterisk) in the ascending aorta. Asc Ao, Ascending aorta.
gr3.jpg
PMC9871350_01_gr3.jpg
fig3
Since the pseudoaneurysm was located in the distal ascending aorta, a high upper esophageal view was required to keep it in the view (Figure 3). II, which has 12 mm disks, was placed at the neck of the pseudoaneurysm (Figure 6, Videos 2 and 3). Initial placement appeared adequate angiographically, but TEE highlighted that a portion of the aortic disk may have been deployed into the pseudoaneurysm neck (Video 4), prompting us to reposition the device and deploy once properly placed.
Intraprocedural TEE images showing the ascending aorta and the pseudoaneurysm in short axis from an upper esophageal view. (A) Two-dimensional mode shows the location of the PSA; (B) color Doppler reveals systolic flow into the PSA cavity, which is partially thrombosed. Asc Ao, Ascending aorta; PSA, pseudoaneurysm.
gr4.jpg
PMC9871350_01_gr4.jpg
fig4
By TEE, the pseudoaneurysm had a neck of 7 x 8 mm and the sac measured 31 x 26 x 18 mm, with a partially thrombosed cavity (Figure 4, Video 1).
Pulsed-wave Doppler at the neck of the pseudoaneurysm shows the "to-and-fro" waveform representing blood going in and out of the cavity during the cardiac cycle.
gr5.jpg
PMC9871350_01_gr5.jpg
fig5
Pulsed-wave Doppler at the neck of the lesion demonstrated bidirectional flow, consistent with the "to-and-fro" pattern classically seen in pseudoaneurysms (Figure 5). The pseudoaneurysm cavity was almost completely thrombosed (Figure 7, Videos 5 and 6), and there was no significant residual leak noted by TEE, although fluoroscopy demonstrated a faint amount of contrast inside the pseudoaneurysm sac, suggesting a trivial leak (Figure 8, Video 7).
Intraprocedural TEE images showing the ascending aorta and the pseudoaneurysm in long axis from an upper esophageal view. (A) Two-dimensional mode with delineation of the PSA and the catheter (arrow); (B) color Doppler enhances the demarcation of the thrombosed portion and helps guide catheter placement. Asc Ao, Ascending aorta; PSA, pseudoaneurysm.
gr6.jpg
PMC9871350_01_gr6.jpg
fig6
II, which has 12 mm disks, was placed at the neck of the pseudoaneurysm (Figure 6, Videos 2 and 3). Initial placement appeared adequate angiographically, but TEE highlighted that a portion of the aortic disk may have been deployed into the pseudoaneurysm neck (Video 4), prompting us to reposition the device and deploy once properly placed. The pseudoaneurysm cavity was almost completely thrombosed (Figure 7, Videos 5 and 6), and there was no significant residual leak noted by TEE, although fluoroscopy demonstrated a faint amount of contrast inside the pseudoaneurysm sac, suggesting a trivial leak (Figure 8, Video 7).
Intraprocedural TEE image after device deployment (arrow). (A) Color Doppler with no evidence of residual leak; (B) three-dimensional view with echogenic material below the device consistent with thrombus formation. Asc Ao, Ascending aorta; PSA, pseudoaneurysm.
gr7.jpg
PMC9871350_01_gr7.jpg
fig7
The pseudoaneurysm cavity was almost completely thrombosed (Figure 7, Videos 5 and 6), and there was no significant residual leak noted by TEE, although fluoroscopy demonstrated a faint amount of contrast inside the pseudoaneurysm sac, suggesting a trivial leak (Figure 8, Video 7).
Aortic angiography in left anterior oblique view showing the device (arrow) with a trivial residual leak. Asc Ao, Ascending aorta.
gr8.jpg
PMC9871350_01_gr8.jpg
fig8
The pseudoaneurysm cavity was almost completely thrombosed (Figure 7, Videos 5 and 6), and there was no significant residual leak noted by TEE, although fluoroscopy demonstrated a faint amount of contrast inside the pseudoaneurysm sac, suggesting a trivial leak (Figure 8, Video 7).
Follow-up chest CT with transverse view showing the device (arrow) in a well-seated position in the ascending aorta with a completely thrombosed cavity. Asc Ao, Ascending aorta.
gr9.jpg
PMC9871350_01_gr9.jpg
fig9
Surveillance CT performed 3 days after the percutaneous intervention revealed a stable closure device with decreased pseudoaneurysm size and no residual leak (Figure 9).