Endovascular stent-grafts, prosthetic grafts placed over expandable stents, are an alternative therapy for the treatment of arterial aneurysms, pseudo-aneurysms, dissections, penetrating ulcers and coarctations. However, there are limitations to their applicability. Described here is a patient with Takayasu’s arteritis, an inflammatory disease of medium- to large-sized vessels, who developed a discrete pseudo-aneurysm in an open surgically placed aortic graft. She had previously undergone two separate surgeries for the treatment of thoracic aortic aneurysms. Due to the potential for reduced morbidity and mortality, endovascular stenting was a rational approach for a focal graft defect. Endovascular stent-graft repair could not be performed because the ratio of the required vascular sheath to peripheral vessel size was prohibitive in this patient. Instead, endovascular therapy using an Amplatzer patent foramen ovale occluder device was delivered within the pseudo-aneurysm to seal the connection to the aortic lumen. With radiographic and clinical follow up at 34 months, the patient has done well and not required any additional procedures. J INVASIVE CARDIOL 2008;20:E19–E22

Figure 1.

Subtraction angiograms of the descending thoracic aorta. ( A) Nonselective anterior-posterior angiogram with a pigtail catheter demonstrates the pseudo-aneurysm (arrow). ( B) Selective right anterior oblique angiogram with a Judkins right (JR) 4 catheter of the pseudo-aneurysm.

       Case Report. A 22-year-old female presented to an outside hospital with back pain radiating to the epigastrum. The patient had a history of hypertension and Takayasu’s arteritis. At age 17 she underwent resection of an ascending aortic aneurysm via a median sternotomy with placement of a graft to the aortic arch and banding of the sino-tubular junction because of significant aortic regurgitation. Six weeks prior to her presentation with back pain, the patient underwent resection of a descending thoracic aortic aneurysm via a left posterior-lateral thoracotomy and placement of a 26 mm graft. This included resection of a portion of the aortic arch (hemi-arch) to the descending thoracic aorta just cranial to the diaphragm.

Figure 3.

Transesophageal echocardiography was performed during the procedure. ( A) Transverse images (0 degrees) of the lumen of the descending thoracic aorta (*), the area of blood and thrombus (§), and the focal defect (arrow) of the echogenic walls of the aortic graft material are depicted. Notice how far the imaging probe is away from the aortic lumen. (B) Regional expansion selection (RES) of the defect within the aortic graft material. The opening was measured at approximately 4 mm. (C) Longitudinal images of the descending thoracic aorta depicting the proximal limb of the device within the lumen. The distal limb of the device is not well seen due to acoustic shadowing of the device.

Figure 2.

Right anterior oblique fluoroscopy of the descending thoracic aorta. (A) Both the distal limb (arrow) and the proximal limb (dashed arrow) of the device are deployed but not released from the delivery catheter and no tension is exerted. The arrowhead is the transesophageal echocardiography imaging probe. (B) Tension placed on the proximal limb of the device demonstrates stable placement without movement of the distal limb within the pseudo-aneurysm. (C) Subtraction angiogram using a pigtail catheter of the descending thoracic aorta after the device was released from the delivery catheter. This demonstrates no extravasation of contrast into the pseudo-aneurysm.

       The workup in this patient with back pain occurring 6 weeks post-operation included computed tomographic (CT) imaging with intravenous contrast. This demonstrated a pseudo-aneurysm arising from a focal defect of the mid portion of the recently placed descending thoracic aortic graft. The patient was hemodynamically stable and transferred to our institution on the same day she presented to the emergency room of the outside hospital.
       Endovascular stent-graft repair was anticipated. Upon arrival to our institution, the patient was taken immediately to conventional invasive X-ray angiography, which confirmed that the pseudoaneurysm arose from a focal defect in the mid portion of the descending thoracic aortic graft at the level of the main pulmonary artery (Figure 1). The aortic graft in the transverse dimension measured 30 mm, which had increased in size from the 26 mm graft placed at surgery. The focal defect was amenable to endovascular stent-graft repair; however, angiography of the femoral and iliac vessels demonstrated a transverse size of 6.5 mm. In order to place the appropriate-sized endovascular stent-graft, at least a 20 Fr arterial sheath (diameter of 6.7 mm) would need to be used. However, this was too large a size to be safely placed in the patient’s peripheral vessels.
       Because of the focal nature of the pseudo-aneurysm and the inability to place an endovascular stent-graft, the use of endovascular occluder devices was contemplated. With the consent of the patient’s family and institutional review board under compassionate use guidelines, an Amplatzer patent foramen ovale (PFO) occluder device was used to seal the connection between the aortic graft lumen and the focal pseudoaneurysm immediately after angiography was performed (Figure 2). A 5 Fr Judkins right (JR) 4 catheter was advanced into the pseudoaneurysm over a movable-core 0.035 inch wire. The JR 4 catheter was replaced with an 8 Fr transseptal sheath, then the distal limb of an 18 mm Amplatzer PFO occluder device was successfully deployed in the pseudo-aneurysm. After deployment of the distal and proximal limbs of the PFO device, it appeared to be flat against the aortic graft wall. Tugging on the device demonstrated adequate and stable placement. Transesophageal echocardiography was utilized for guidance during the procedure (Figure 3). Angiography after device placement demonstrated no evidence of contrast within the pseudo-aneurysm (Figure 2C).
       On the following day after percutaneous closure of the pseudoaneurysm, the patient underwent a repeat CT with intravenous contrast, which demonstrated adequate placement of the device without contrast extravasation (Figures 4 and 5). The patient was discharged home the day following the procedure on daily aspirin therapy. With radiographic and clinical follow up at 34 months, the patient has done well and not required any additional procedures (Figure 6).

Figure 5.

(A) Maximal intensity projection (MIP) CT of the thoracic aorta after device implantation. The white arrow demonstrates the distal limb of the device and the red arrow demonstrates the outline of proximal limb of the device. No contrast is noted in the pseudo-aneurysm. The green arrow demonstrates the caudal portion of the thoracic aortic graft. The pseudo-aneurysm did not occur at the graft anastomoses. (B) Fluoroscopy of the device shows a similar contour. (C) MIP CT demonstrating the device at a different angle.

Figure 4.

CT pre- and post-device placement. (A) Contrast study predevice placement depicting the descending thoracic aortic lumen (*), contrast within the contained pseudo-aneurysm (arrow), and a large area (‡) of blood and thrombus now walled off from the pseudo-aneurysm. ( B) Non-contrast study post-device placement demonstrates the device with the distal limb within the pseudo-aneurysm and the proximal limb within the aortic lumen. (C) Contrast study post-device placement demonstrating the device again without extravasation of contrast into the pseudo-aneurysm.

       Discussion. This patient had a complication of Takayasu’s arteritis, progressive aortic aneurysmal disease. Medical therapy is the mainstay of treatment for patients with Takayasu’s arteritis and is aimed at halting the inflammatory process with the use of immune-modulating medicines.¹ Surgical therapies are primarily aimed at the treatment of symptoms of end-organ ischemia due to critical stenoses with vessel bypass or preventing the risk of dissection/rupture due to aneurysmal disease by vascular reconstruction with graft material.¹

Figure 6.

Non-contrasted CT obtained 34 months after device placement demonstrates resolution of the pseudoaneurysm with stable placement of the device within the aorta.

       The leading cause of surgical complications in patients with Takayasu’s who have undergone surgery is anastomotic aneurysms.² The patient described in this report underwenttwo prior aortic reconstructive surgeries. Because of this, the initial concern was that this pseudo-aneurysm was likely secondary to the surgical anastomotic site where there may have been impaired healing between the graft and native aorta. Upon close inspection, the pseudo-aneurysm did not occur at the anastomotic site, but rather in the mid portion of the graft (Figure 5). This is a very uncommon finding. It is our hypothesis that the pseudo-aneurysm was caused by the intraoperative measurement of pressure within the graft by needle catheterization connected to fluid-filled tubing and expansion of the puncture site over time. This is not infrequently performedintraoperatively to ensure there is no increased intra-aortic pressure secondary to malposition of the graft. However, pseudo-aneurysms arising from needle catheterization sites are not common.
       Open surgical repair was an option, but given this patient’s clinical course to date, it seemed probable that the patient would need future thoracic surgical repair. To minimize this, an endovascular approach using a stent-graft was considered a rational approach due to its likelihood of reduced morbidity and mortality. However, the patient’s peripheral vessel size for delivery of a stent-graft device was a limitation. An Amplatzer PFO occluder device was felt to be an acceptable device for several reasons: the device can be placed using an 8 Fr catheter (diameter of 2.7 mm); the design of the device was considered to allow for a favorable conformation to the arterial wall; and the narrow waist of the PFO occluder device (in comparison with the atrial septal occluder (ASD) device) was considered favorable in its design by limiting additional force to the graft material and potentially enlarging the hole. The ease of removability of the device was also favorable in the event the device did not perform as desired during implantation.
       Percutaneous closure of vascular defects/structures is a therapeutic option with reduced mortality and morbidity. However, the risks and benefits must be individualized to each case and surgical consultation is strongly recommended. Stent-grafts are an option, but require larger vascular access sheaths. Other endovascular devices requiring smaller vascular access sheaths have been used for closure of a surgical graft anastomotic leak (Amplatzer ASD)³ or endoleaks from stent-graft placements (Amplazter vascular plug).⁴ Utilizing some of the devices may be an off-label indication, and operators and patients should be aware of this. This case report describes the successful use of a percutaneously placed Amplazter PFO occluder device to close an aortic pseudo-aneurysm arising from an aortic graft.