Transcarotid Endovascular Exclusion of an Ascending to Descending Aortic Bypass Pseudoaneurysm

A 46 year-old woman with a history of Shone complex status post patch repair of the aorta and ductus ligation, aortic valve replacement, mitral membrane myectomy, and aortic coarctation repair by ascending to descending aorta bypass with Dacron presented with known pseudoaneurysm at the descending thoracic aortic anastomosis (Figs 1 and 2). She had a failed attempt at endovascular repair using an Amplatzer plug with continued perfusion and was symptomatic despite aggressive blood pressure control. The cardiac surgeon deemed her too high risk for open repair and recommended palliation. The vascular surgery service was consulted for possible endovascular options. Because of the complex nature of the problem, a Gore iliac branch endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) was used to seal the pseudoaneurysm and to maintain flow through both the bypass and her native thoracic aortic segment. This was accomplished by accessing the right common carotid artery and establishing through-and-through wire access by the Dacron bypass and out the right common femoral artery. Once the wire was in place, the IBE main body was inserted from the carotid with the main limb being deployed into the prior bypass. A 27-mm limb was used to seal in the bypass graft. The wire was then removed, and femoral access was used to cannulate the contralateral gate, and it was snared from the carotid access. A 23-mm limb was then used to seal in the native aorta. An 11-mm Gore VBX stent was postdilated to 16 mm to preserve preferential flow through the bypass limb. On completion imaging, there was good flow through the device and no further evidence of filling into the pseudoaneurysm. Repeated computed tomography on postoperative day 4 and at 1 month showed no further active bleeding into the pseudoaneurysm with good flow through both limbs. Her pain has since resolved. Unfortunately, she died 5 months postoperatively as a result of a motor vehicle accident. This was a complicated problem with no available open options in a young patient. Because of the complex nature of the problem, a commercially available device was used off-label to correct the pseudoaneurysm. This is the first reported use of the transcarotid deployment of the Gore IBE device. Further imaging will be needed to determine long-term patency and need for further interventions in the future.Fig 2Postoperative CT scan after successful exclusion of the pseudoaneurysm by novel trans-carotid deployment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)