Experts from NYU Langone’s Center for Complex Aortic Disease received a high-risk referral for a patient requiring emergent repair of a softball-sized, palpable, expanding pseudoaneurysm of the ascending aorta located at the clavicle, as well as treatment for an infected aortic graft. A successful patient outcome included three separate procedures and was facilitated by the integration of cardiac and vascular surgical teams, coupled with multidisciplinary nursing and rehabilitation expertise.
Expanding Pseudoaneurysm and Related Symptoms Require Prompt Action
A 62-year-old man with a type A aortic dissection underwent placement of an aortic graft at another hospital in 2015. He experienced a prolonged recovery, complicated by sternal graft infection that required incision and drainage of the sternum, wire removal, and reconstruction flap at the same hospital. In 2017, he developed fungemia due to graft infection and was placed on chronic suppression therapy after treatment. In August 2019, after initiation of Eliquis® for deep vein thrombosis, the patient developed a bulge at his clavicle the size of a softball. The palpable mass was identified as an expanding pseudoaneurysm of the ascending aorta.
The patient was referred to Aubrey C. Galloway, MD, the Henry H. Arnhold Chair and Professor of Cardiothoracic Surgery and cardiac surgery director of the Center for Complex Aortic Disease, and Thomas Maldonado, MD, the Schwartz Buckley Professor of Surgery and director of vascular surgery at the Center for Complex Aortic Disease. Ultimately the patient underwent a high-risk emergency repair of the ruptured pseudoaneurysm with removal of the infected graft, replacement of the ascending aorta and debranching bypass to the innominate artery followed by delayed left carotid subclavian bypass and endovascular stent graft repair of a chronic 5.9-cm aneurysm in the distal aortic arch and proximal descending aorta.
In mid-September 2019, before a scheduled consultation with Dr. Galloway, the patient presented to an emergency department (ED) in New Jersey complaining of severe chest pain. A CT scan revealed an expanding 6.7-cm pseudoaneurysm anterior to the mid and upper ascending thoracic aorta. The patient was discharged from the ED in stable condition and encouraged to follow up at NYU Langone. At the initial appointment with Dr. Galloway the patient reported that he had been having severe chest pain over the previous week, which was now continuous and keeping him up at night. A large, tender, pulsating mass was visible in his lower neck above his clavicle. Dr. Galloway recommended immediate hospitalization for repair of the pseudoaneurysm with removal of the infected graft. The patient had planned to defer surgery for a week but was ultimately admitted for tight blood pressure control followed by emergent surgery on October 8.
Open Repair of Ruptured Pseudoaneurysm Precedes Endovascular Repair of Distal Aneurysm
The patient was admitted to NYU Langone and stabilized in the intensive care unit (ICU). Imaging studies obtained after the patient’s admission revealed a 6.9-cm pseudoaneurysm of the ascending aorta and proximal aortic arch, with a bovine arch and a 5.6-cm chronic aneurysm distally in the upper descending thoracic aorta. The aortic valve was normal, and the aortic root was not aneurysmal. The surgical team anticipated rupture of the aneurysm upon opening the chest and therefore planned to initiate cardiopulmonary bypass with profound systemic body cooling (deep hypothermia) before opening the breastbone. Circulatory arrest was planned upon chest entry, followed by removal of the ruptured pseudoaneurysm and infected graft.
“NYU Langone is a pioneer in the field of endovascular aneurysm repair.”—Thomas Maldonado, MD
After induction of general anesthesia and confirmatory transesophageal echocardiogram, the patient’s head was packed in ice, and cardiopulmonary bypass was initiated, core cooling the patient’s blood to 18 degrees Celsius. The aneurysm ruptured freely upon opening of the chest, and blood flow was stopped with circulatory arrest. After removal of free blood and clot, the rupture site was identified at the lower graft anastomosis. The pseudoaneurysm and infected graft were excised down to the aortic root. A short graft was placed to the bovine innominate artery and connected to the heart–lung machine to restore blood to the head and brain before proceeding with arch replacement. The innominate artery was then detached from the arch and sutured to the side graft for subsequent debranching. The remainder of the ascending aorta and arch were excised out to zone 2 of the arch (adjacent to the left subclavian artery) and replaced with a graft from this area down to the aortic root. The bovine innominate artery side graft was then connected to the ascending aortic graft to complete the debranching process.
The patient was rewarmed, cardiopulmonary bypass was discontinued without difficulty, and hemostasis was confirmed. The patient was soon transported to the cardiac surgical critical care unit with stable hemodynamics. Following the seven-hour procedure he experienced a small perioperative stroke, but recovered his neurologic function nicely. After physical therapy and cardiac rehabilitation, he was able to walk a number of blocks without difficulty, with only a small degree of residual toe numbness.
Delayed Carotid Subclavian Bypass and Endovascular Repair of a Distal Arch Aneurysm
The patient was seen in clinic in May 2020, and an open left carotid subclavian bypass was planned to safely cover the origin of the artery, in preparation for a later endovascular stent graft repair of the upper descending aneurysm.
The patient’s final procedure was scheduled for July 22. After induction of general anesthesia, Dr. Maldonado exposed the common carotid artery anterior to the sternocleidomastoid. The subclavian artery was dissected through a supraclavicular incision and encircled with vessel loops before surgeons tunneled a 6-mm Propaten® graft below the sternocleidomastoid and administered heparin. The common carotid was then clamped proximally and distally, and an arteriotomy was performed. After the graft was beveled, the anastomosis was created and the clamps were removed and placed on the graft. An arteriotomy was then performed with graft placement at the subclavian artery in the same fashion.
Next, the bilateral common femoral arteries were accessed and sheaths placed, with placement of a ProGlide® device for later percutaneous closure of the right common femoral artery. A pigtail catheter was advanced over guidewire via the left side and positioned in the ascending aorta, after which an aortogram was performed to evaluate the aneurysm and confirm arterial patency.
A catheter was advanced into the ascending aorta over guidewire, which was then exchanged for a stiff Lunderquist® wire. A Gore® Tag® conformable stent graft was advanced and deployed at the level of the deep branch bypass from the ascending aorta. The delivery system was removed, and a Tri-Lobe balloon was used to mold all areas of attachment and overlap. A completion aortogram demonstrated an excellent result, with complete filling of the bypass and no evidence of endoleak. Wires, catheters, and sheaths were removed, manual compression was placed on the left, and 20 mg of intravenous (IV) protamine was administered to return activated clotting time to normal. Percutaneous closure of the right femoral artery was then followed by manual compression and application of sterile dressings. The patient was extubated and returned to the recovery room without complications.
The patient was doing well at follow-up with Dr. Maldonado in August, less than 12 months after his initial consultation at NYU but almost 5 years after the initial repair of the type A dissection. “NYU Langone is a pioneer in the field of endovascular aneurysm repair,” Dr. Maldonado says. “We were one of the initial centers in the United States to test early endograft techniques in the 1990s, and we continue to test new endovascular devices for complex aneurysm repair.”
“Our approach is patient-centric,” Dr. Galloway adds. “Each case is reviewed from planning to execution by an experienced multidisciplinary team to determine the best approach to complex aortic disease tailored to each individual’s anatomy, pathology, and underlying risks. At the same time, institutional best practices, including infection control and tailored rehabilitation, minimize the risk of complications and ensure optimized return to health for each patient.”