Optimal Management of Aortic Arch Coarctation With Large Pseudoaneurysm

This video is part of CTSNet’s 2024 Resident Video Competition. Watch all entries into the competition, including the winning videos.  

A 50-year-old female presented with asymptomatic aortic coarctation and a large aortic arch pseudoaneurysm, which was discovered during a health screening. Her CT scan showed a 5 cm pseudoaneurysm in the mid-to-distal arch, with coarctation distal to it. 

The patient had normal heart function with mild pulmonic and tricuspid regurgitation, a high blood pressure gradient (50 mmHg) between the upper and lower extremities, but no significant pressure gradient between the left and right upper extremities. 

The optimal approach included endovascular repair following a left carotid subclavian transposition. Thoracic endovascular aortic repair (TEVAR) had the potential to exclude the pseudoaneurysm, but a backup plan was necessary due to a short proximal landing zone. The backup plan involved open arch replacement with a modified frozen elephant trunk (FET). 

Initially, surgeons attempted to pass a wire from the femoral access; however, they were unable to navigate through the pseudoaneurysm as the wire became caught. The plan was then to pass another wire from the right radial access to snare the wire across the pseudoaneurysm. 

The upper wire successfully entered the descending aorta, allowing the authors to body-floss the wires. This allowed access both proximally and distally to the pseudoaneurysm. The first angiogram revealed a large pseudoaneurysm and a coarctation in the arch, with significant contrast filling the pseudoaneurysm. 

Next, the authors prepared to deliver the coarctation stent. They delivered and centered the stent in the coarctation, planning to exclude the pseudoaneurysm as well. After performing another angiogram, the surgeons prepared to deploy the stent. The coarctation stent appeared to be positioned correctly, and the stent was further expanded and reinforced with ballooning. The angiogram showed adequate expansion of the stent, but there was persistent filling of the pseudoaneurysm. 

Another right anterior oblique (RAO) view angiogram was performed to identify the source of the persistent filling. The authors initially suspected the defect was at the distal aspect and decided to place a distal stent. However, there was still some proximal filling, indicating a type 1a endoleak. Another proximal covered stent was placed to exclude it, but the small leak remained, and there was not enough proximal landing zone for another stent. 

The authors planned to observe the outcomes after reversal of anticoagulation. Two separate post-TEVAR CT scans showed persistent endoleak and filling of the pseudoaneurysm. Therefore, the surgeons decided to proceed with a zone 2 arch replacement using a FET. The key operative steps are shown in the video. 

After arterial and venous cannulation, the surgeons dissected around the innominate artery, divided it, and began the anastomosis to the head-first graft. The anastomosis between the innominate artery and the head-first graft was completed from back to front. 

Next, attention was turned to the left common carotid artery, which was isolated in a similar fashion and divided using a stapler. The left common carotid artery was then anastomosed to the head-first graft. Additional dissection around the ascending aorta was performed. The Bavaria graft (soft trunk) planned for insertion into the distal arch was trimmed, and the aorta was resected to zone 2. 

The inside of the arch was inspected, and the previous TEVAR stent was identified. Efforts were made to locate the opening into the arch pseudoaneurysm, followed by additional dissection around the arch. After inspecting the arch, it was determined that it would be difficult to insert a buffalo trunk (pre-sewn FET) as usual, due to a very short landing zone for the FET caused by the previous TEVAR stent. A modified FET technique was decided upon, beginning with the insertion of the soft Bavaria trunk into the arch, followed by the deployment of a short antegrade TEVAR stent. 

The soft Bavaria trunk was then pushed into the arch, and the anastomosis of the body of the Bavaria graft to the arch was initiated. Approximately one third of the way through the anastomosis, the graft was trimmed, its interior was inspected, and the soft trunk was smoothed, confirming it was within the previous stent. After ensuring that the graft was positioned appropriately, the anastomosis was completed in a counterclockwise fashion. The short FET was then placed to bridge the soft trunk and the previous TEVAR stent using a TBE cuff. After completing the distal anastomosis, attention was turned back to the proximal end to finalize the anastomosis between the Bavaria graft and the sinotubular junction. Subsequently, the anastomosis between the Bavaria graft and the head-first graft was completed. The zone 2 arch replacement with modified FET was completed, and rewarming of the patient began. 

The complex arch anatomy and existing TEVAR stent may complicate the insertion of a long antegrade FET stent in traditional approaches. A stent was not added that would exacerbate the coarctation. The soft elephant trunk provided an optimal proximal landing zone for the short FET stent cuff bridging to the previous TEVAR stent. Care was taken to avoid displacing the existing TEVAR stent and to select the correct graft size to ensure optimal proximal landing zone sealing. The postoperative CT showed a well-seated new stent graft within the arch, with no filling of the pseudoaneurysm noted after the open repair. 

References

1. Lala S, Scali ST, Feezor RJ, Chandrekashar S, Giles KA, Fatima J, Berceli SA, Back MR, Huber TS, Beaver TM, Beck AW. Outcomes of thoracic endovascular aortic repair in adult coarctation patients. J Vasc Surg. 2018 Feb;67(2):369-381.e2. doi: 10.1016/j.jvs.2017.06.103. Epub 2017 Sep 22. PMID: 28947226.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.