Comment
Our case illustrates the novel use of TEVAR to prevent the catastrophic and real potential for embolic stroke on challenging re-entry for aortic PSA repair. This is a rare entity, and previous cardiac surgery is the most common cause of ascending PSA. While endovascular repair has successfully been applied as primary therapy, anastomotic constraints as well as common co-existence of infection may preclude it, requiring open repair. We recognize from prior experience that clots migrating from the PSA into the aorta during the circulatory arrest and sternal opening represent a high embolic risk. To mitigate this risk, we introduced a novel hybrid approach, in which TEVAR was used to prevent embolism of the large volume of hematoma within the pseudoaneurysm. The TEVAR graft accomplished 2 goals: prevention of embolic stroke and maintenance of selective antegrade cerebral perfusion during circulatory arrest.
Although this case represents a unique clinical scenario, requiring an innovative solution, we believe that the interplay between endovascular and open surgical techniques showcased here serves as an excellent example of the potential strategies that could develop and progress the state of the art in aortic surgery and underscores the need for cardiothoracic surgeons to develop a familiarity and skillset with endovascular techniques moving into the future.
References
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Figure 1. Preoperative CT angiogram demonstrating a bilobed pseudoaneurysm arising from the ascending aorta, just proximal to the aortic arch takeoff measuring 3.6 x 2.8 cm with a large peri-aortic and mediastinal hematoma.
Figure 2. Fluoroscopic image of the TEVAR graft positioned in the proximal aorta
Figure 3. Fluoroscopic image taken after deployment of the TEVAR graft into the ascending aorta.