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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3590_Библиотеки_им_академика_М_И_Перельмана
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Fig. 29.4 Bench testing on 3D printed patient-specific cardiac models. Printed cardiac 3D soft model
representing tissue characteristics was used to determine the best access site and guiding catheter to engage the subaortic pseudoaneurysm. Transapical (A) access allowed for the most coaxial and feasible approach compared with transseptal (B) access. A 6F left coronary bypass guiding catheter (A) provided the
best coaxial engagement of the pseudoaneurysm, followed by a Judkins right 4 guide (C). Amplatz Left-1
guiding catheter did not provide a great fit, given the narrow left ventricular outflow tract. (Reproduced with
permission from Al-Hijji MA, Guerrero M, Rihal CS, Eleid MF. Transapical percutaneous closure of rapidly
expanding post-surgical left ventricular outflow tract pseudoaneurysm. Catheter Cardiovasc Interv.
2019;94(6):859-862.)
Guidelines and Patient Selection
There are no specific guidelines for the treatment of pseudoaneurysms. Fig. 29.5 outlines our
approach to management.
The indications for treatment may include:
n
Symptoms
n
Acute complications of MI
n
Acute complication of a structural/electrophysiologic procedure
n
High risk of rupture (Laplace law: Wall stress 5 Pressure * radius / 2)
n
Presence of thrombus and risk of thromboembolism.
29—PSEUDOANEURYSM DIAGNOSIS AND MANAGEMENT 347
sN
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Aortic/LV pseudoaneurysm
Heart team evaluation
Further anatomical
evaluation:
• Gated CT scan
(3D reconstruction)
• MRI
• TEE (2D and 3D)
• Wide pseudoaneurysm
neck for percutaneous device
• Undergoing cardiac surgery
for concomitant disease
No
Anatomy is suitable for
percutaneous closure
Apical/aortic
location
Approach
Ye
Posterobasal/mechanical
aortic valve
• High risk of rupture
(e.g., rapid expansion)
• Acute complications
of MI/structural/
electrophysiology procedure
• Presence of thrombus and
risk of thromboembolisim
Ye s
Surgical repair
Small/
moderate size
Device
type
Large size
Double mechanical valves/
certain paravalvular locations
• Conservative therapy
with close follow-up
o
and serial cardiac
imaging
• Anticoagulation if risk
of bleeding not high
Endovascular
Occluder devices
(AVP, ASD, VSD
occluders)
coils
Retroaortic
approach
Fig. 29.5 Approach to the management of pseudoaneurysms.
Conservative Management
Minimal data are available on conservative management of pseudoaneurysms. In a systematic
review of 31 patients who were managed conservatively, 48% died at a median of 1 week, with
the remainder of patients alive at a median of 156 weeks.
vives the early period after pseudoaneurysm formation and their risk of surgical or percutaneous
treatment is considered prohibitive, conservative management may be appropriate. However, this
should be pursued with caution, and very close follow-up with serial imaging is important.
Transeptal
approach
Direct apical
approach
1
This suggests that if the patient sur-
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We previously published a case of conservatively managed LV pseudoaneurysm after endocardial
ablation in a congenital heart disease patient with a single ventricle.
11
The patient was considered
at prohibitive risk for repeat surgery and percutaneous closure carried a high risk of interfering
with the single mechanical valve. The patient was followed serially with CT scans for 3 months
(available follow-up until 1 year) without any change in the size of pseudoaneurysm. She was
already on anticoagulation for the mechanical valve.
In patients who are managed conservatively, anticoagulation is recommended to reduce the
risk of thrombus formation and systemic embolism.
Percutaneous Closure of Pseudoaneurysms
VENTRICULAR AND AORTIC PSEUDOANEURYSMS
Percutaneous approaches have allowed for a less invasive treatment of pseudoaneurysms. The access to pseudoaneurysms depends on its location. The retroaortic (femoral artery) approach is
usually utilized for apical, posterolateral, and aortic pseudoaneurysms. The antegrade (transseptal)
approach can be used in posterobasal pseudoaneurysms or in patients with a mechanical aortic
valve. A transapical approach may be required in patients with double (aortic and mitral) mechanical valves or if the pseudoaneurysm is not reachable, such as in cases of a left ventricular
outflow tract (LVOT) pseudoaneurysm (Fig. 29.6). TTE is used to identify the true apex, and the
transapical puncture site is marked using a sterile marker. Using fluoroscopic imaging, the transapical puncture is performed with 16-cm gauge 3 10-cm Angiocath needle and a 6F sheath is
introduced. Catheters are introduced through this sheath, and the occluder device and/or endovascular coils are deployed. The transapical access is closed using 4- to 6-mm AVP II plug after
removal of the sheath.
The following techniques can be used to approach percutaneous closure of pseudoaneurysms
(Figs. 29.11 to 29.19 describe the procedural steps for percutaneous closure using various methods.):
n
Occluder devices
n
Coil embolization
n
Combination of occluder device and coil embolization
12
Occluder Devices
Occluder devices are usually used for moderate or large pseudoaneurysms. Preprocedure CT or
magnetic resonance imaging (MRI) scans are studied in detail to measure the size of the pseudoaneurysm and width and length of the neck of the pseudoaneurysm. In addition, the landing
zone of the occluder devices and any chances of impinging or interfering with surrounding structures such as coronary arteries and valve leaflets can be assessed.
Occluder devices that can be used include the Amplatzer Vascular Plug II (AVP II) (St. Jude
Medical, St. Paul, MN) and septal duct occluders (Amplatzer ASD or VSD Occluder, AGA,
Minneapolis, MN). These devices are made of braded nitinol mesh with micro-interlocked struts.
They are attached to a 155-cm stainless steel cable that allows for device repositioning before
final release. The device accelerates fibrin-mediated thrombogenesis by substantially reducing
flow across the nitinol mesh. A plan for the type of device and size should be made based on the
pseudoaneurysm size and risk of interference with surrounding structures. We usually place an
occluder device that is 50% wider than the pseudoaneurysm neck to ensure a complete seal. The
devices are not significantly oversized, to limit the risk of impingement and compression of surrounding structures. The procedure is performed under conscious sedation and local anesthesia,
unless transesophageal echocardiography (TEE) is required to assess for interactions with other
cardiac structures such as mechanical valves in patients with paravalvular pseudoaneurysm. Intracardiac echocardiography (ICE) can be used instead in patients who are at high risk for general
anesthesia.
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Fig. 29.6 Direct transapical access for left ventricular outflow tract (LVOT) pseudoaneurysm closure.
(A) Fluoroscopic image of transapical access guided by pressure tracings. (B) Successful placement of left
coronary bypass (LCB) guide catheter in the subaortic pseudoaneurysm (yellow arrow). (C) Subaortic pseu-
doaneurysm was successfully sealed using a 10-mm AVP II device (yellow arrow) with contrast injection
showing reduced flow to the pseudoaneurysm. (D) The transapical access site was successfully closed with
a 4-mm AVP II device (yellow arrow). (Reproduced with permission from Al-Hijji MA, Guerrero M, Rihal CS,
Eleid MF. Transapical percutaneous closure of rapidly expanding post-surgical left ventricular outflow
tract pseudoaneurysm. Catheter Cardiovasc Interv. 2019;94(6):859-862.)
For a retrograde approach, a 6F to 8F sheath is inserted in the femoral artery using ultrasound
guidance. A biplane left ventriculogram or aortogram is performed for LV and aortic pseudoaneurysms, respectively. Adjustments may be required to clearly outline the neck of the pseudoaneurysm.
We typically start with a 6F multipurpose guide catheter with a telescoping 5F 125-cm multipurpose diagnostic catheter and extra-support angled hydrophilic 0.0350 wire (Glidewire, Terumo
Medical Corp., Somerset, NJ) to engage the pseudoaneurysm. Different guiding catheters may have
to be utilized depending on the location of the pseudoaneurysm.
After advancing the guide catheter, a selective angiogram of the pseudoaneurysm is performed. After this, an Amplatz extra-stiff 0.0350 wire (Cook Medical, Bloomington, IN) is advanced in the pseudoaneurysm and the guide catheter is replaced by a shuttle sheath. Leaving the
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wire in place (anchor safety wire), an occluder device is deployed with its narrowest diameter
across the neck of the pseudoaneurysm. Next, fluoroscopic and echocardiographic evaluation is
performed to assess for device stability and any possible mechanical effects on adjacent valvular
or other structures. Selective or nonselective coronary angiography can be performed if there is
concern of vessel compression before full device release in LVOT pseudoaneurysms.
An angiogram is performed to confirm there is no leak around the device. Further confirma-
tion is obtained using TTE, TEE, or ICE. The wire is removed and the device is released if there
is no impingement or compression on surrounding structures. A repeat biplane angiogram is
performed to confirm complete closure.
Antegrade (transseptal) access may be required in paramitral valve pseudoaneurysms and in
cases where the retrograde approach is not feasible, such as in patients with a mechanical aortic
valve. In those cases, a steerable and flexible sheath such as 8.5F Agilis Steerable NxT Introducer
(St. Jude Medical, St. Paul, MN), along with the telescoping catheters, is used to provide a wide
range of reach to engage the pseudoaneurysm. Other steps are similar to what has been described
earlier. Figs. 29.7 to 29.9 show the step-by-step approach to percutaneous closures of LV and
aortic pseudoaneurysms with occluder devices.
Coil Embolization
For smaller pseudoaneurysms with a very narrow neck, endovascular coils can be used to
plug the pseudoaneurysm. Care must be exercised to avoid any extension of the coils into
the LV or aorta. For this approach, initial steps include femoral artery access, biplane angiogram, selective engagement of the pseudoaneurysm, and placement of the guiding catheter.
ABC
DEF
Fig. 29.7 Percutaneous closure of left ventricle (LV) apical pseudoaneurysm with occluder devices.
(A) Wire injury related to a mitral valve-in-ring procedure. (B) Left ventriculogram demonstrated an apical
pseudoaneurysm. (C) Engagement of pseudoaneurysm was performed using a retroaortic approach with
telescoping guiding catheter. (D) Deployment of AVP II plug was performed with the distal disc and body in
the pseudoaneurysm and the proximal disc covering the outlet. (E) Check on angiography before releasing
the plug demonstrated no contrast flow in the pseudoaneurysm sac. (F) The plug was stable after release.
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C
DE
Fig. 29.8 Percutaneous closure of an aortic pseudoaneurysm with occluder devices. (A) Aortogram
demonstrated the neck and extent of pseudoaneurysm. (B) The pseudoaneurysm was engaged using a
retroaortic approach with telescoping 6F multipurpose guide; a 5F 125-cm diagnostic multipurpose catheter was sent over a stiff angled Glidewire. (C) Selective injection of the sac showed the neck (white arrow)
and extent of a large pseudoaneurysm. (D) An AVP II plug was deployed successfully. (E) Repeat angiogram
showed complete closure.
Commercially available endovascular coils can be placed within the sac to completely obliterate the cavity. Repeat angiogram is performed to confirm complete closure after partial
reversal with protamine. Detachable coils such as EV3 Axium (EV3 Endovascular, Inc.,
Peripheral Vascular, Plymouth, MN) are preferable to allow for controlled release and closure. Snares should be available in the catheterization laboratory for retrieval in cases of
inadvertent coil embolization or prolapse into the aorta or ventricular cavity. Fig. 29.10 shows
an example of LV pseudoaneurysm closure with endovascular coils.
Tables 29.2 and 29.3 outline the technical considerations and advantages and disadvantages
of using coils versus occluder devices.
12
13
Combined Occluder Device and Coil Embolization
In very large pseudoaneurysms or those with multiple lobes or incomplete closure with occluder device alone, a combined approach can be used. Similar steps are used to engage the
pseudoaneurysm, followed by deployment of the occluder device. A 4F multipurpose catheter is then advanced over the wire into the pseudoaneurysm and the wire is removed. Endovascular coils are then introduced with complete packing of the sac. The occluder device
is secured in position to make sure there is no extension or embolization of coil outside the
pseudoaneurysm sac.
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Fig. 29.9 Percutaneous closure of basal left ventricle (LV) pseudoaneurysm with occluder devices. (A) Left
ventriculogram showed an inferobasal pseudoaneurysm in a patient with a prior history of mitral paravalvular
leak closure; however, the neck was not clearly visible. (B) Repeat left ventriculogram with a different angle
showed the neck. (C) The pseudoaneurysm was engaged using a retroaortic approach and injected selectively.
(D) The AVP II plug was deployed successfully with no flow across the neck.
CORONARY AND GRAFT PSEUDOANEURYSMS
Coil and Noncovered Stent or Covered Stent
Coronary artery pseudoaneurysms are rare but can develop secondary to vascular trauma
from previous intervention, vasculitis, or spontaneous dissection. Coronary bypass graft
pseudoaneurysms can also develop in degenerated vein grafts. This can be associated with
angina because of steal phenomenon, and is also associated with an increased risk of
thrombosis and occlusion of the graft in addition to an increased risk for rupture. Coil
embolization across a noncovered stent is a commonly utilized technique to minimize the
risk of coil prolapse into the main vessel and subsequent thrombosis (Fig. 29.20).
dition, covered stents like the Graftmaster or peripheral stents such as Viabahn can be
used to exclude the pseudoaneurysm. Fig. 29.21 shows an example of a vein graft we
treated with a Viabahn (W. L. Gore & Associates, Flagstaff, AZ) polytetrafluoroethylenecoated, nitinol, self-expanding peripheral stent.
15
The use of covered stents in coronary
arteries requires long duration of dual antiplatelet therapy, as the risk of stent thrombosis
and subsequent MI is high. Therefore covered stent use is limited in coronary aneurysms
and pseudoaneurysms.
14
In ad-
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A
B
C
Fig. 29.10 Percutaneous closure of pseudoaneurysm with endovascular coils. Magnetic resonance imaging
of the chest shows a 2.3-cm pseudoaneurysm at the left ventricle apex (A). Left ventricular angiography
demonstrated the pseudoaneurysm with a neck (B). Using a guiding catheter and microcatheter, the pseudoaneurysm was engaged and 11EV3 AXIUM detachable coils were used (C). Completion of left ventricular
angiography revealed no flow into the pseudoaneurysm (D). (Reproduced with permission from Rahim SA,
Greason KL, Bjarnason H, Rihal CS. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 2009;54(8):740.)
TABLE 29.2 n Technical Considerations for Percutaneous Coils and Occluder Devices in Treatment
of Cardiac Pseudoaneurysms
Property of
Pseudoaneurysm Coils Occluder Devices Comment
Size of
pseudoaneurysm
Guide in device
selection
Small to
moderate sized
Volume of
pseudoaneurysm
D
Any size
Dimensions of neck 3D CT with segmentation anal-
ysis can assist in volumetric
assessment and endocardiac visualization for 3D
anatomy of the neck to size
the devices appropriately.
Continued on following page
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TABLE 29.2 n Technical Considerations for Percutaneous Coils and Occluder Devices in Treatment
of Cardiac Pseudoaneurysms (Continued)
Property of
Pseudoaneurysm Coils Occluder Devices Comment
Anatomic location of
pseudoaneurysm
Relationship to epi-
cardial coronaries
Relationship to
valves
CT, Computed tomography; LAD, left anterior descending artery; LVOT, left ventricular outflow tract.
Reproduced from Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic
approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv. 2012;80(4):687-699.
Posterobasal or
posterolateral;
LVOT and apical
Less of concern Left circumflex in
Less of concern Mitral valve apparatus in
Apical, posterobasal,
posterolateral, or
LVOT
posterobasal or
posterolateral pseudoaneurysms; left
main or LAD in LVOT
pseudoaneurysms
posterobasal or posterolateral pseudoaneurysms; aortic valve
apparatus in LVOT
pseudoaneurysms
Coronary angiography during
device deployment,
3D segmentation analysis,
and bench testing on 3D
printed cardiac models
might be helpful to avoid
mechanical complications.
Septal occluder devices may
be the device of choice in
pseudoaneurysms adjacent
to periprosthetic mitral regurgitant leaks requiring closure.
TABLE 29.3 n Advantages and Disadvantages of Percutaneous Coils and Occluder Devices in
Treatment of Cardiac Pseudoaneurysms
Coils Occluder Devices
Technically easier Can be technically challenging
Suitable for small or moderate sized
pseudoaneurysms
May result in incomplete closure More likely to result in complete closure
Can be used for any anatomic
location
Mechanical effects are less of
concern
Not ideal for periprosthetic
pseudoaneurysms
LVOT, Left ventricular outflow tract.
Reproduced with permission from Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous ther-
apeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv. 2012;80(4):687-699.
Can be used for even larger pseudoaneurysms
Careful case selection for posterobasal and LVOT pseudoaneu-
rysms
Mechanical effects onto coronaries or valves are a concern in
LVOT and posterobasal pseudoaneurysms
May be a good choice for periprosthetic pseudoaneurysms, es-
pecially if the periprosthetic leak requires concomitant closure.
Complications
Immediate complications may include incomplete closure and embolization of occluder devices
or coils. The operators should be competent with using different snares in this setting. Incomplete
closure can be problematic, as it may lead to further enlargement of the pseudoaneurysm and the
potential for thrombus communication with the systemic vascular system.
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Fig. 29.11 For a retrograde approach, a 6F to 8F sheath is
inserted in the femoral artery using ultrasound guidance.
After the aortogram, we engage the pseudoaneurysm. We
typically start with a 6F multipurpose guide catheter with a
telescoping 5F 125-cm multipurpose diagnostic catheter and
a stiff-angled Glidewire to engage the pseudoaneurysm. Different guiding catheters may have to be utilized depending on the
location of the pseudoaneurysm.
Fig. 29.12 After advancing the guide catheter, a selective
angiogram of the pseudoaneurysm is performed. After this,
an Amplatz extra-stiff 0.0350 wire is advanced in the pseudoaneurysm and the guide catheter is replaced by a shuttle sheath.
Fig. 29.13 Leaving the wire in place, an occluder device is
inserted.
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