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).