Case report
The patient is a 12-year-old, 43 kg, male with 22Q11.2 deletion syndrome, coarctation of the aorta, and a monocuspid aortic valve with severe stenosis. He underwent coarctation repair on day 6 of life. He then had 2 surgical aortic valve repairs—at 4 months and 5 years old. At 12 years old, he’d developed recurrent severe aortic valve stenosis with mild regurgitation and was scheduled for reoperation. A Ross-Konno procedure was performed involving aortic valve replacement with a pulmonary autograft, aortoventricular septoplasty, and pulmonary valve replacement with a 26 mm pulmonary homograft. The procedure was uncomplicated—with a well-functioning neo-aortic valve, pulmonary homograft conduit, and hyperdynamic left ventricular function.
On post-operative day 22, a routine echocardiogram demonstrated a pseudoaneurysm from the left ventricular outflow tract measuring 1.3 cm × 2.5 cm. The echocardiogram was otherwise reassuring. A CT angiogram (Image 1) and 3D reconstruction (Image 2) were performed, which demonstrated a pseudoaneurysm arising 10 mm below the non-coronary cusp of the aortic valve with a narrow 3 mm neck. It measured 30 mm × 14 mm × 17 mm, extending postero-laterally within 1.3 mm of the left anterior descending coronary artery. The patient remained well and asymptomatic. A follow-up CT angiogram 5 weeks after surgery showed no change in the size of the pseudoaneurysm.
CT angiogram in axial and coronal planes demonstrating the pseudoaneurysm (black asterix) and its proximity to the proximal LAD (red arrow).
Image 1. Long description
A CT angiogram in axial and coronal planes showing a pseudoaneurysm marked by a black asterisk and its proximity to the proximal left anterior descending artery indicated by a red arrow. The pseudoaneurysm is located in the left ventricular outflow tract and measures 1.3 centimeters by 2.5 centimeters. The image provides a detailed view of the internal structures and the spatial relationship between the pseudoaneurysm and the proximal LAD.
3D reconstruction of the CT angiogram demonstrating the pseudoaneurysm in green.
Image 2. Long description
The image presents a 3D reconstruction of a CT angiogram, highlighting a pseudoaneurysm in green. The pseudoaneurysm is located in the left ventricular outflow tract. The surrounding structures include the branching arteries and the main arterial trunk, all depicted in red. The pseudoaneurysm is clearly visible as a distinct, green-colored area, indicating its size and position relative to the other anatomical features.
The patient was discussed at our institution’s Joint Cardiac Conference. The consensus was for transcatheter occlusion of the pseudoaneurysm. Given the proximity to the aortic valve, device occlusion of the neck carried risk of impacting aortic valve function; and proximity to the left anterior descending coronary artery raised concern for coronary compression. We utilised Penumbra coils to occlude the pseudoaneurysm with high packing density and minimising outward pressure on the left anterior descending coronary artery.
The procedure was performed under general anaesthesia. Vascular access was obtained with a 6-French sheath inserted in the right femoral artery. Heparin was given to maintain ACT over 200 s. A 6-French pigtail catheter was advanced retrograde across the aortic valve, and a left ventriculogram was performed, demonstrating the pseudoaneurysm arising from the left ventricular outflow tract below the non-coronary cusp of the aortic valve and extending postero-laterally. A 6-French Judkins Right guide catheter was advanced to the left ventricle. A 5-French Bern catheter was then advanced through the Judkins Right Guide Catheter into the pseudoaneurysm. A 2.6 French Lantern Delivery Microcatheter was then advanced through the Bern Catheter into the pseudoaneurysm. Coil occlusion of the pseudoaneurysm was performed with seven Penumbra coils: two 24 mm × 60 cm Ruby Standard Coils, a 20 mm × 60 cm Ruby Soft Coil, a 16 mm × 50 cm Ruby Soft Coil, an 8 mm × 35 cm Ruby Soft Coil, and two 15 cm Packing Coils.
A post-embolisation ascending aortogram was performed and demonstrated no aortic regurgitation and no coronary artery compression. The pseudoaneurysm was densely packed (supplement 1) with no residual flow identified on imaging. There were no procedural complications. The patient’s post-procedure course was uncomplicated from a cardiac standpoint; however, his admission was prolonged due to a rhinovirus infection. He was discharged on day 3 post-procedure.
The patient has remained well at follow-up 12 months post-procedure. Echocardiograms have demonstrated no recanalisation of the pseudoaneurysm with no left or right ventricular outflow tract obstruction.
Discussion
Left ventricular outflow tract pseudoaneurysms are a rare but known complication following cardiac surgery, endocarditis, and transcatheter closure of ventricular septal defects. Reference Kim, Ban, Lee, Sung, Kim and Choi1,Reference Breinholt, Rodefeld and Hoyer2 Traditionally, these pseudoaneurysms have been repaired with surgery due to the risk of life-threatening rupture; however, case reports have described transcatheter occlusion. Reference Elshershari, Gossett and Hijazi3 We have described the first case of a left ventricular outflow tract pseudoaneurysm being occluded with Penumbra Embolisation Coils.
Our patient developed a pseudoaneurysm following cardiac surgery, which has been reported in both adults and children. Reference Elshershari, Gossett and Hijazi3 These defects have traditionally been closed surgically due to the risk of pseudoaneurysm rupture; however, there are now several case reports of transcatheter interventions to close ventricular pseudoaneurysms.
Previous reports of transcatheter pseudoaneurysm intervention in children predominantly describe device occlusion using the Amplatzer Vascular Plug Reference Kim, Ban, Lee, Sung, Kim and Choi1 or Amplatzer Septal Occluders. Reference Gokalp, Ugan Atik and Saltik4 Only four cases have reported the use of coils for cardiac pseudoaneurysm embolisation in children. One in the posterior left ventricle, Reference Breinholt, Rodefeld and Hoyer2 two in the left ventricular outflow tract, Reference Elshershari, Gossett and Hijazi3,Reference Srivastava and Hoyer5 and one from the left ventricle apex. Reference Haddad, Bou Houssein, Adel Hassan and Kasem6
Only Haddad et al. Reference Haddad, Bou Houssein, Adel Hassan and Kasem6 described the use of Penumbra Coils in a child’s heart. They described the occlusion of the apical pseudoaneurysm secondary to percutaneous device closure of an apical muscular VSD in a 3-year-old female. The 14 × 14 mm pseudoaneurysm was successfully occluded with a Penumbra 14 mm × 60 cm Ruby Standard Coil and a subsequent packing coil.
Penumbra Embolisation Coils are detachable platinum-based bare metal coils delivered via a microcatheter and designed for occlusion of peripheral aneurysms. Reference Teigen, Moyle and Patel7 These coils have mostly been used for embolisation of arteriovenous malformations, cerebral aneurysms, peripheral vasculature aneurysms, and vessel sacrifices. Reference Teigen, Moyle and Patel7 The coils are reported to allow high packing density, which has been described as increasing occlusion stability and decreasing recanalisation rates. Reference Vogler IV, Gemender and Samoilov8 We particularly favoured use of these coils in this case to achieve high packing density and minimise outward pressure on the nearby left anterior descending coronary artery. The ability to deploy and re-capture coils of substantial length prior to release allowed for additional security to minimise the risk of coil embolisation. Further, given the proximity of the pseudoaneurysm to the aortic valve, we were concerned that device occlusion would carry a risk of impingement on aortic valve function, and device deployment might be technically challenging given the angle of approach and location of the pseudoaneurysm. Through this approach we achieved complete occlusion without procedural complications.
In summary, a left ventricular outflow tract pseudoaneurysm post Ross-Konno procedure was successfully occluded in a child via a transcatheter embolisation with Penumbra Embolisation Coils. Transcatheter pseudoaneurysm occlusion can be safe and effective, avoiding the need for redo sternotomy and surgical excision.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1047951126113407.
Data availability statement
As a single case report, this data is not publicly available.
Acknowledgements
We acknowledge and thank the patient and family for consenting to publishing this case.
Financial support
The authors did not receive support from any organisation for the submitted work.
Competing interests
Nil conflicts of interest to declare.
Ethical standard
Consent has been obtained from the patient’s guardian for publication of this case report.
