Discussion
This report describes a successful closure of an AAP with endovascular management in a ten-year-old patient. Aortic pseudoaneurysms are rare complications in cardiovascular surgery that occurs in less than 0.5% of patients (4,6). Similarly, this complication is infrequent concerning HT, and it is rarer among pediatric patients (7,8). This complication has a morbimortality rate between 29 and 46% (6). Its pathogenesis is based on the weakness of at least one layer of the aorta, and the blood is contained by fibrous tissue or pericardium (1,9). Some predisposing factors are graft infection, trauma, tissue fragility in the anastomosis area, aortic cannulation sites, cardioplegic cardiac puncture, a dissected native aorta, and tissue necrosis due to biological glue (1,2,10).
The clinical features can be dyspnea, hemoptysis, chest pain, respiratory failure, and cardiogenic shock (4,10,11). Although, patients can remain asymptomatic, and pseudoaneurysms are incidental findings of imaging exams (1,4). Usually, small pseudoaneurysms do not cause clinical manifestations, but a periodical follow-up is needed to surveillance the dimensions and to reevaluate possible therapeutic options (1). Likewise, within the reported complications are the pseudoaneurysm rupture, local compression, and erosion of surrounding tissues, sources for infection and thrombus (2,4,10). In this case, the patient was hemodynamically stable, and the only clinical feature was a cardiac murmur. Therefore, the diagnosis was incidental with a MSCT.
The conventional management is the open surgery with the resection of the pseudoaneurysm. Reoperations are associated with extensive bleeding or cerebral air embolism during resternotomy (4). In the literature, most patients with a history of heart transplantation were treated by surgery (8,12,13). However, in high-risk patients, some authors have proposed new alternatives such as using Atrial Septal Defect occluder, vascular plugs, stents, coil embolization, and thrombin injection with favorable outcomes (3–5). Endovascular management is less aggressive and associated with less blood loss and shorter procedural durations (3,4).
Additionally, Joyce et al. published a case report of an adult patient with lung-heart transplantation who was treated by an endovascular approach with favorable outcomes (14). Nevertheless, the complications are endoleaks, open conversion, migration of the stents, and myocardial infarctions. Thereby, it is recommendable a close follow-up of these patients (3,11). The patient presented was considered for endovascular management due to his high-risk factors, location of the AAP, non-compromise of the coronary ostia, and previous experience of our cardiopediatric team with similar procedures. Besides, some authors suggest that the landing zone of the stent in the ascending aorta must be at least 2 cm and aortic diameter less than 40 mm, which was possible to achieve in our patient (11,15).