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 follow-up appointment, the patient reported three or four episodes of severe chest pain over the previous week. 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
Imaging studies obtained after the patient’s admission to NYU Langone revealed a 6.9-cm leaking pseudoaneurysm, a distal 5.6-cm aneurysm in the upper descending aorta from the prior dissection, a bovine arch, and no landing zone for repair of the pseudoaneurysm with a stent graft. The aortic valve was normal with no leakage, and the aortic root was not dissected or aneurysmal. The surgical team anticipated rupture of the aneurysm upon opening the chest and recommended extreme systemic hypothermia before making the skin incision. Surgeons planned to repair the ruptured pseudoaneurysm of the ascending aorta and remove the infected graft before replacing the ascending aorta and zone-two hemi-arch with debranching bypass of the innominate and left carotid arteries. The patient was stabilized in the intensive care unit (ICU) before the procedure.
“NYU Langone is a pioneer in the field of endovascular aneurysm repair.”—Thomas Maldonado, MD
After induction of general anesthesia and confirmatory transesophageal echocardiogram, surface cooling began before initiation of cardiopulmonary bypass. The aneurysm ruptured freely upon opening of the chest, and after removal of free blood and clot, the rupture site was identified at the lower graft anastomosis. Next, the infected graft was excised, followed by resection of the distal ascending aorta into the mid-transverse aortic arch with removal of the bovine innominate artery for subsequent grafting. A thrombosed false lumen was identified on the undersurface of the arch, extending into the distal aorta. The graft was sutured to the bovine innominate artery followed by placement of the arch graft at the mid-distal native aortic arch adjacent to the left subclavian artery. A sidearm of the innominate artery graft was inserted into the arch graft to restore perfusion before rewarming.
After injection of cardioplegic, the infected graft proximal to the sinotubular junction and valve commissures was dissected, and the distal arch and isthmus aneurysm were identified for later endovascular repair. The arch graft was then sutured to the aortic root, and an end-to-side anastomosis was constructed between two grafts. Hemostasis was confirmed, and the patient was rewarmed. The side arm of the arch graft was transected, cardiopulmonary bypass was discontinued, and the patient was soon transported to cardiac critical care with stable hemodynamics. He experienced a perioperative stroke following the seven-hour procedure, but after physical therapy and cardiac rehabilitation, he recovered with only residual toe numbness and was able to walk a number of blocks without difficulty.
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, to be followed by a later endovascular stent graft repair of the 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.”