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.