2. • Nothing to disclose related to this presentation
Disclosures
3. Clinical Presentation
• A 79-year-old male patient was referred to us by
cardiothoracic surgery for endovascular repair for
saccular aneurysm ATAA due to his risk comorbidities
Aortogram showed a
saccular ascending
thoracic aortic
aneurysm
4. o Initially, he was diagnosed with ATAA after he sustained
a cardiac arrest, ventricular fibrillation, he was
cardioverted by paramedics and was admitted to the
hospital
o He underwent Coronary Angiography which revealed no
evidence of CAD, Aortogram showed a saccular ATAA
o ICD was implanted for secondary prevention of SCD
o PMH: HTN, h/o SBE with Mitral regurgitation, atrial
fibrillation, cardiac arrest, ventricular fibrillation, recent
ICD obesity, MV repair
5. Our Plan
• Due to high surgical risk and comorbidities including
previous mitral surgery, recent cardiac arrest and the
anterior location of the aneurysm and close proximity to
the sternum, we decided to proceed with
“ endovascular repair of ascending aortic thoracic
aneurysm under local anesthesia, conscious
sedation, percutaneous approach with RV pacing ”
6. Procedural Technique
The procedure was done in the endovascular suite
Access :
A percutaneous access using micropuncture technique
in both CFAs and 6 Fr sheaths were placed in the right
and left CFAs
Venous access in the left CFV with 6 Fr Sheath, used for
temporary pacemaker of the RV for rapid RV pacing
during deployment
A 10 Fr Prostar device was used to preclose the right
CFA, and 6 Fr Proglide was used to preclose the left
CFA.
9. From the Right CFA access, the aortic valve was
crossed using regular J wire and JR5 Catheter.
The wire then was exchanged with .035” Lunderquist
that was positioned inside the LV cavity.
Progressive dilatation of the ipsilateral side with 14, 16,
18 Fr sheaths was performed successfully.
A 22 Fr. Medtronic sheath was placed with no
complications.
12. Second Valiant (44 mm x 80
mm length) stent graft
overlapped with first graft
Angiography after
deployment of the endograft
revealed a significant
foreshortening and
presence of small endoleak
17. Learning points
To the best of our knowledge, we are reporting the first
case of endovascular repair of ATAA under local
anesthesia, conscious sedation, percutaneous approach
with RV pacing.
The current standard treatment of ATAA is the surgical
approach as endovascular repair is very challenging due
to the anatomical complexities including the origin of aortic
arch vessels, hemodynamic forces, respiratory motion,
angulation of the inner aortic curvature and proximity to
the coronary/Innominate arteries and the aortic valve.
There are no specific devices designed and approved for
this purpose.
18. In our patient, a successful repair of ascending
aortic aneurysm has been performed under local
anesthesia, and that combination of TEVAR of
ascending aorta with local anesthesia &
conscious sedation is what makes this case
unprecedented and could be used in the future in
the appropriate settings as an alternative to more
invasive approaches.
Computed Tomography Angiography (CTA) of the chest revealed a saccular ascending aortic aneurysm originating approximately 3 cm from the left coronary artery and ending 3 cm from the origin of the Innominate artery.
Left common femoral vein access -> 6 Fr x 75 cm long sheath was advanced over the wire and fluoroscopy guidance to the right atrium. Through this sheath, 5 Fr Balloon tipped Pacemaker catheter was introduced and advanced to the apex of the RV for rapid pacing.
The pacemaker was connected and tested for rapid pacing during graft deployment at later stage.
Afterwards, the patient's AICD was temporarily turned off.
A 5 Fr. marker pigtail (20 markers) was then introduced under fluoroscopic guidance into the thoracic aorta and placed at the right coronary sinus.
A 50 cc injection was performed with digital imaging to assess the aneurysm and determine the anatomical relationship with the left coronary artery and the Innominate artery.
Next, 5 Fr Pigtail catheter was advanced through Left CFA and advanced to the ascending aorta for marking the innominate artery at the time of deployment.
Next, we advanced Valiant (44 mm x 44 mm x 80 mm length) stent graft to the ascending aorta.
The device was deployed under fluoroscopy guidance and rapid ventricular pacing to 180 BPM to reduce cardiac output and stabilize the graft, keeping in mind the distance from the left main coronary artery.
Angiography obtained after the deployment of the endograft revealed a significant foreshortening of the endograft and presence of small endoleak;
Angiography obtained after the deployment of the endograft revealed a significant foreshortening of the endograft and presence of small endoleak;
We advanced second Valiant (44 mm D x 80 mm L) stent graft to the ascending aorta, and the device was deployed under fluoroscopy guidance and rapid ventricular pacing to 180 BPM to reduce cardiac output and stabilize the graft, keeping in mind the distance from the innominate artery which was protected using pigtail catheter.