Case 1
A 28-year-old male presented in 2010 with chest pain following amphetamine use. CXR revealed a grossly enlarged and peripherally calcified descending thoracic aortic aneurysm with rib notching (Fig. 1). CT angiogram confirmed a 5.7 cm calcified aneurysm distal to a 5 mm lumen TAC (Fig. 2), and florid predominantly posterior collaterals. The chest pain persisted despite medical therapy. Alternative causes for the pain were excluded. Discussion at the complex cardiothoracic disease multi-disciplinary team (MDT) meeting concluded that the extent of collateralisation posed a high risk of uncontrollable bleeding. An endovascular approach was preferred, this was agreed with the patient.
Under general anaesthesia (GA), with a cardiothoracic team on stand-by, an 18Fr sheath (Cook, Bloomington, IN) was inserted via a right common femoral artery (CFA) surgical cut down with a left CFA 6Fr sheath. The procedure predates our routine use of large arterial access closure devices. The small TAC lumen was hard to identify within the large aneurysm. It was eventually crossed with a 4Fr vertebral catheter and hydrophilic wire (Terumo, Japan). A 260 cm Amplatz wire (Cook) was placed across the TAC into the left subclavian artery (LSCA) for emergency TEVAR or balloon control in the event of bleeding.
Over 10 intercostal and bronchial arteries arising from the aneurysm sac were coiled using a combination of 0.035 in. Nester (Cook), 0.035 MReye coils (Cook) Trufill platinum micro coils (Cordis, Miami, Florida) and one Amplatz AVP1 10 mm plug (AGA Medical, Plymouth, Minnesota,). TAC 8 mm pre-dilatation facilitated TEVAR delivery. A 21 mm × 100 mm Gore TAG device (W. L. Gore, Flagstaff, AZ) was deployed immediately distal to the LSCA. A 39 mm length uncovered CP stent (NuMED, Hopkinton, New York,) mounted onto a 16 mm outer BIB balloon (NuMED) was delivered flush with the cranial stent graft with serial inflations leading to good apposition resulting in almost complete abolition of the coarctation and exclusion of the aneurysm (Fig. 3). Procedure time was 5 h. CT angiography at 72 h confirmed complete aneurysm exclusion.
Over 7 years CT surveillance showed aneurysm sac shrinkage to 4.2 cm with no endoleak. Eight years post operatively the patient presented with left sided weakness secondary to emboli from culture negative infection associated with intravenous drug use. Echocardiography identified a mitral valve vegetation. CT angiogram and PET-CT showed no evidence of infection at the site of the coarctation and aneurysm repair. Treatment was with long term IV antibiotics. At 10 years CT follow-up the aneurysm remains excluded and at a stable reduced size with no recurrence of the TAC.
Patient 2
A 29 year old female was referred from another regional specialist cardiothoracic centre. She was well until 2017 when she developed a painful left foot. Septic emboli due a Streptococcal sanguis endarteritis at the site of previously undiagnosed coarctation, with a 3.5 cm aneurysm distal to it, was diagnosed. The aneurysm had numerous large collateral vessels, and two lateral out-pouchings measuring 6 x19mm and 11 × 9 mm which were considered most likely to be pseudoaneurysms (Fig. 4). After 6 months of intravenous antibiotic therapy and imaging surveillance, she was referred for operative treatment. CT angiogram demonstrated an 8 mm coarctation 3 cm distal to the LSCA with an unchanged aneurysm (Fig. 4). Considering the infectious clinical presentation, preference to avoid an interposition graft with a suture line and high bleeding risk the MDT offered an endovascular repair.
Under GA, aneurysm sac collaterals were embolised via a 5Fr right CFA sheath using Trufill micro-coils (Cordis) and Amplatzer AVP4 vascular plugs (AGA Medical). These included superior intercostal arteries, bronchial arteries, broncho-intercostal arteries, and posterior intercostals connecting to the internal mammary arteries. No residual aneurysm sac collaterals were seen on completion aortic angiography. Surgical formation of a 10 mm distal aortic conduit was required for TEVAR delivery as the 5 mm iliac arteries were too narrow in calibre. The tip of an 80 cm 5Fr Flexor sheath (Cook) from a left CFA access was left within the aneurysm sac in case collateral embolisation was incomplete. A 31 mm × 100 mm Gore TAG stent graft (W. L. Gore) was deployed distal to the origin of the LSCA. A 39 mm length covered CP stent (NuMED) was dilated to 24 mm to treat the aortic coarctation (Fig. 5).
After exclusion of the aneurysm, angiography via the long sheath in the aneurysm sac demonstrated two patent non-embolised collateral branches (Fig. 5). These were embolised using a catheter and Progreat microcatheter (Terumo, Japan) combination and 10 × 14 micronester coils (Cook). No complication occurred. A 5 day post-operative CT showed no endoleak. She remains asymptomatic over 3 years of follow-up with a stable aneurysm sac and no endoleak.