Case Report
A nine-year-old male with a past medical history of refractory heart failure due to non-ischemic dilated cardiomyopathy underwent to bicaval/unipulmonar technique for orthotopic heart transplantation (HT) after four weeks of waiting time. In the postoperative course, the child presented biventricular failure, acute 1R cell rejection, and nosocomial pneumonia that were satisfactorily resolved. Therefore, he was discharged with immunosuppressive treatment with prednisone, tacrolimus, and mycophenolate mofetil, 21 days after HT.
Three months later, the child presented with fever, arthritis, dyspnea, and a heart murmur. A blood culture tested positive to methicillin-sensitive Staphylococcus aureus , and he started receiving antibiotic therapy with oxacillin and clindamycin until testing negative during the control. A transthoracic echocardiogram showed no signs of endocarditis. Then, a multi-slice computed tomography (MSCT) evidenced a 16.2 mm x 14.2 mm pseudoaneurysm in the left side of the aortic anastomosis area (Figure 1). There was a distance of 30 mm from the neck to the left coronary ostium. In MSCT reconstruction, there was a mass compatible with an AAP in the same location (Figure 2). Through catheter-based aortography (CBA), the AAP was confirmed, measuring 17 mm x 16 mm (Figure 3A, Supplemental Video 1) with a neck of 6.8 mm with blood flow, and a diameter of 18 mm from the ascending aorta. The coronary arteries were not compromised.
After several discussions among our cardiopediatric team, the child was deemed as a high-risk surgical patient because of his medical background and the location of the AAP. Thereby, the percutaneous endovascular approach of the pseudoaneurysm was indicated. Unfortunately, it could not be done promptly due to logistical failures and the stabilization of infection. Besides, the patient was evaluated periodically by the cardiopediatric department, and no new clinical features were reported. However, a MSCT performed after eight months revealed an increase in the lesion’s measures to 20.5 mm x 18.4 mm without clinical changes or hemodynamic instability. Therefore, the patient was scheduled to perform endovascular treatment.
The patient was admitted to perform the interventional procedure to close the AAP. After the dissection of the left common carotid artery and the puncture of the artery by Seldinger’s technique under direct vision, an 8-French sheath was inserted, and a 0.035” J-guide. Then, a 5-French pigtail catheter was positioned to the side of the AAP, and the findings were confirmed. The J-guide was changed to an Amplatz Super Stiff 0.035”, and the access was upgraded to a 14-French sheath. Then, a 39 mm covered Cheatham Platinum (CP) stent pre-mounted on an 18 mm x 4 cm / 9 mm x 3 cm balloon in balloon (BIB) catheter was advanced to the side of the AAP under CBA guidance. After the manual CBA-controlled insufflation of the inner balloon followed by the 6-atm-controlled insufflation of the outer one, it was evidenced residual blood flow into the AAP and a slight distal displacement of the stent (Figure 3B). Thereby, a second stent with greater length was needed. The first BIB catheter was removed, and a 45 mm covered CP stent pre-mounted on a 20 mm x 5 cm / 10 mm x 4 cm BIB catheter was advanced toward the location of the first stent under CBA guidance. The balloons were insufflated consecutively with the same technique, followed by a control CBA, which showed the patency of the coronary ostia and absence of perfusion of the AAP (Figure 3C, Supplemental Video 2). Finally, the catheters were removed, and the carotid artery was closed by purse-string suture with 7/0 polypropylene. The patient left the operating room extubated and in spontaneous breathing. Then, he was admitted to 24-hour routine surveillance in the Intensive Care Unit.
The patient remained hemodynamically stable and had a favorable evolution. He was discharged with an indication of 100mg daily of acetylsalicylic acid for six months. After a five-month follow-up, the patient was asymptomatic and without complications reported.