D600214

A 53-year-oldman with history of hypertension presented with ascending aortic aneurysm andsevere aortic regurgitation underwent Bentall procedure with 26 mm conduit and mechanicalaortic valve in 2021.  

Chestcomputed tomography revealed aortic root pseudoaneurysm, which measured 8.8 x6.4 cm in the mediastinum, with mural thrombus inside. Coronary buttondehiscence with pseudoaneurysm are diagnosed, where the entry point is rightnext to the re-implantation site of left main coronary artery. Transesophagealechocardiography showed a huge pseudoaneurysm right next to the aortic valveprosthesis, connectedwith orifice of left main coronary.

A hugepseudoaneurysm right next to the aortic valve prosthesis, connectedwith orifice of left main coronary, with systolic pulsatile flow from the aortainto the pseudoaneurysm cavity. 
Video A.AVI

UnderTEE and fluoroscopic guidance, the pseudoaneurysm was selectively engaged with a7F Judkins right coronary guide catheter, followed by passage of two 0.014” coronaryguidewire to increase support, while a second 6F Judkins right guide catheterintroduced through contralateral femoral access was used to engage left maincoronary artery, followed by passage of one 0.014” coronary guidewire into terminalleft anterior descending coronary artery. Sequentially, we then used a guideextension to cross pseudoaneurysm, then introduced Confida pre-shaped guidewire, and finally 7F Judkins right coronary guide catheter was passed into thepseudoaneurysm. The Judkins right guide catheter facilitated for a 5F shuttlesheath, for placement of an 6 x 4mm Amplatzer Duct Occluder. Meanwhile, a drug-eluting stent was standby inleft anterior descending coronary artery by using guide extension catheter. Amplatzer Duct Occluder II 6 x 4mm was deployed at the entry point ofcoronary button dehiscence under TEE guidance, and immediate thrombus formationwas demonstrated. Owing to partial protrusion of occluder into leftmain coronary artery, the 4.0 x 15mm drug-eluting stent which was standby in leftanterior descending artery was pull back and deployed consecutively. Three-dimensionalechocardiography showed patent left main coronary artery after occluderdeployment and left main coronary stenting. Finalangiogram and TEE showed well-seated devices with minimal residual leak.

Post-Bentall pseudoaneurysms were reported in 6% to 10% of patientsdue to anastomotic and coronary dehiscence. Even though surgical repair ofpseudoaneurysms following aortic surgery can be safely performed with goodlong-term outcomes, these procedures carry high mortality and prolongs hospitalstay. In ourpatient, the pseudoaneurysm bleed originated at the anastomosis of the aorticroot graft involving the left coronary button. Cathetermanagement in post-Bentall pseudoaneurysms is limited.4 To the best of ourknowledge, there has been no specific prior report addressing simultaneousoccluder deployment and coronary stenting.