Author + information
- Deshpande Shantanu1
Patient initials or identifier number
Relevant clinical history and physical exam
A young 25-year-old female, presented with dyspnoea since 3 months and had dyspnoea at rest (NYHA grade IV) two weeks prior to presentation. She also had dull chest pain along with a persistent dry hacking cough. On examination, she was breathless at rest and orthopneic. She was on therapy for the treatment of tuberculous pericardial effusion since last 7 months. Her SPO2 was 90% in sitting position and 70% in a supine position. Air entry reduced on left side. XRC fig1, ECHO.
Relevant test results prior to catheterization
On further investigation with a computed tomography (CT) scan, it found that she had a pseudoaneurysm arising from the undersurface of the aortic arch originating opposite to the origin of the right subclavian artery. This aneurysm was extending up to the sternum. Echo review suggested a communication neck measuring 9 mm between the arch of aorta and aneurysm.
Relevant catheterization findings
A review angiography in the left anterior oblique and lateral view revealed a 9 mm opening within the undersurface of the aortic arch.
Under local anesthesia, a 7 French bi femoral access was taken. A review angiography in the left anterior oblique and lateral view revealed a 9 mm opening within the undersurface of the aortic arch. Communication entered using a 6F JR catheter with the help of a 300 cm Terumowire. A 7F long Cocoon (Vascular Concepts) curved sheath inserted into an aneurysm. A curved sheath was selected to overcome angulation of the arch of the aorta. (Fig 1) A 10 mm Cocoon ASD device was inserted, and its position was checked with contralateral aortic pigtail shoot in both RAO and LAO views and with transthoracic echocardiography. A device released after confirmation of sealing of communication on Echocardiography and angiography. (Fig 2) A small leak remained on echocardiography and angiography post procedure. Her follow-up echocardiography showed 90 % thrombosis of an aneurysm on the third day with complete cessation of the leak. The patient showed gradual improvement in saturation over one week. She was discharged on the 7th day. On discharge, her oxygen saturation at rest was 94% in room air. Over a period of three months, her dyspnoea resolved completely, only mild intensity dry cough persisted. Her follow-up CT scan at one month revealed thrombosed residual pseudoaneurysm with central colliquation and device in situ. (Fig 3).
In our opinion, an ASD device with the use of a curved sheath to overcome the angulation of the aortic arch is a suitable option for selected patients with pseudoaneurysm with good immediate and medium term outcome. Relative ease and safety of the procedure in hands of an experienced operator may lead to this procedure becoming the treatment of choice in selected patients. The immediate benefit of occlusion may be a due reduction in systolic pressure inside a pseudoaneurysm resulting in reduced pressure on the pulmonary artery. We demonstrated a successful use of ASD device in a patient with spontaneous pseudoaneurysm with immediate and a one year follow up.