Abdominal Aortic Pseudoaneurysm Repair Using the Amplatzer®
Septal Occluder Device

Case Report. An 81-year-old male with a prior history of open abdominal aortic aneurysm (AAA) repair using a tube graft (24 mm Hemashield Dacron, Meadox Medicals, Inc., Oakland, New Jersey) presented for treatment of a pseudoaneurysm. Ten years after the surgery, on routine contrast computed tomography (CT) surveillance imaging of the aneurysm graft, he was found to have a pseudoaneurysm measuring 3.7 x 2 cm (Figures 1A and B and Figure 2). The pseudoaneurysm was located at the anterior distal anastomosis of the abdominal aortic graft, 1.5 cm from the bifurcation of the iliac artery. The patient refused surgery and an endovascular approach for treatment of the pseudoaneurysm was chosen. A 15 mm Amplatzer^® septal occluder (AGA Medical Corp., Golden Valley, Minnesota), a type of nitinol- based, self-expanding device, was deployed across the neck of the pseudoaneurysm through the left femoral artery access utilizing a 7 Fr sheath (Figures 3A and B). The device sizing was based on the diameter of the neck of the pseudoaneurysm communicating with the aorta (15 mm). The larger left atrial (LA) disc (29 mm) was positioned within the pseudoaneurysm and the right atrial (RA) disc (25 mm) was on the aorta (Figure 3B). Postprocedural descending aortography demonstrated no flow in to the pseudoaneurysm (Figure 3B). There was no evidence of aortic or any branch artery obstruction and no complications occurred. The patient was on warfarin for a past history of deep vein thrombosis. This was continued following the procedure. No additional antiplatelet/antithrombotic agents were used. At 2-year follow up, the patient continues to do well and the pseudoaneurysm had decreased in size. Contrast CT of the abdomen showed that the device was in the appropriate position. The size of the pseudoaneurysm decreased significantly, and there was no extravasation of contrast media (Figure 4).

Discussion. Graftrelated complications following surgical repair of an AAA have been reported in 7% of patients.¹ These complications contribute subsequently to the patient’s lifetime health problems and mortality risk.^1–3 An aneurysm at the anastomosis site following surgical repair of an AAA is uncommon, occurring in 3% of patients, as described in a large study of 1,087 patients.¹
The natural course of postsurgical aortic pseudoaneurysms is unknown.⁴ These pseudoaneurysms may increase in size and potentially rupture, with catastrophic consequences. Repair is indicated in these situations, 4 as the fatality rate of a pseudoaneurysm rupture is 96.2%.²
Although open surgical treatment has been traditionally used to repair abdominal aortic pseudoaneurysms, more recently, endovascular repair has been favored.4 Endovascular repair avoids the risk of re-do aortic surgery. An endograft can be used to cover the pseudoaneurysm, however, this was not possible in our patient due to the proximity of the pseudoaneurysm to the aortic bifurcation. There are reports of treating postsurgical aortic pseudoaneurysms using endovascular stents, coils and n-butyl.^3–6 The Amplatzer vascular plug has been used to occlude the internal iliac arteries in patients undergoing aorto-iliac aneurysm repair.⁷ The Amplatzer septal occluder has been used for aorto-caval fistula closure in another case report.⁸ To our knowledge, this is the first report of endovascular treatment of postsurgical aortic pseudoaneurysm using an Amplatzer septal occluder. Transcatheter intervention with the Amplatzer septal occluder may be a feasible alternative to surgical repair for treatment of anastomotic pseudoaneurysms following surgical repair of AAA, especially in patients with a high risk for surgery due to associated morbidities.

References

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