Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms

Case Report

Percutaneous Therapeutic Approaches to Closure ofCardiac Pseudoaneurysms

Prasanna Venkatesh Kumar,1 MD, Oluseun Alli,1 MD, Haruldur Bjarnason,2 MD,Donald J. Hagler,3 MD, Thoralf M. Sundt,4 MD, and Charanjit S. Rihal,1* MD

Cardiac and aortic pseudoaneurysms are rare complications following myocardialinfarction or cardiac surgery. They are characterized by a contained cardiac or aorticrupture within surrounding tissue and have a high mortality rate if left untreated. Per-cutaneous treatment of cardiac pseudoaneurysms might be a feasible treatment optionin patients who are at high risk of reoperative surgery. There is limited literature on theoutcomes and the approaches to percutaneous treatment of these pseudoaneurysms.We review nine cases of cardiac and aortic pseudoaneurysms and percutaneous tech-niques for closure. Pseudoaneurysms were categorized anatomically as left ventricularposterior (posterobasal or posterolateral), left ventricular outflow tract, left ventricularapical, and ascending aortic pseudoaneurysms. Two patients with posterior pseudoa-neurysms (one posterobasal treated with an Amplatzer Septal Occluder device, andone wide-mouthed posterolateral pseudoaneurysm which was not closed, aredescribed. We further describe two left ventricular outflow tract pseudoaneurysmstreated successfully with percutaneous coil embolization, one left ventricular apicalpseudoaneurysm treated with coils, and three ascending aortic pseudoaneurysmstreated with a septal occluder device or vascular plug. We review the technicalapproaches, device selection strategies, outcomes, and complications with these per-cutaneous treatment options. The size of the pseudoaneurysm dimensions of its neckand relative anatomy, particularly to the coronaries and valves, are critical issues to beaddressed before percutaneous treatment of these pseudoaneurysms. VC 2012 Wiley Peri-

odicals, Inc.

Key words: cardiac pseudoaneurysms; embolization; vascular occlusion devices

INTRODUCTION

Left ventricular (LV) pseudoaneurysms can occurwhen cardiac rupture is contained by surrounding tis-sues such the pericardium or scar from previous sur-geries or inflammation. It is a rare complication fol-lowing myocardial infarction or cardiac surgeries suchas valve replacement [1]. Posterior LV pseudoaneur-ysms are twice as common as anterior pseudoaneur-ysms [1]. Other reported locations include the lateralwall, apex, and inferior wall. Such pseudoaneurysmsare thought to have a 30–45% risk of rupture and ahigh mortality rate if left untreated [1,2]. In the past,surgical repair has been the preferred treatment modal-ity; however, it is associated with significant operativerisk, especially if combined with reoperative mitralvalve surgery [3]. More recently, however, percutane-ous closure of left ventricular pseudoaneurysms using

1Division of Cardiovascular Diseases, Mayo Clinic, Rochester,Minnesota2Department of Radiology (HB), Mayo Clinic, Rochester,Minnesota3Division of Pediatric Cardiology, Mayo Clinic, Rochester,Minnesota4Division of Cardiovascular Surgery, Mayo Clinic, Rochester,Minnesota

Conflict of interest: Nothing to report.

*Correspondence to: Charanjit S. Rihal, MD, Chair, Division of Car-

diovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester,

MN 55905. E-mail: [email protected]

Received 13 May 2011; Revision accepted 16 December 2011

DOI 10.1002/ccd.24300

Published online in Wiley Online Library (wiley

onlinelibrary.com)

VC 2012 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 00:000–000 (2012)

endovascular coils [4] and septal occluder devices hasbeen described [5,6]; but there are limited data on theoutcomes and complications associated with these tech-niques. We review a series of nine cases with cardiacpseudoaneurysms from our institution treated percuta-neously and discuss their management, technical strat-egies, outcomes, and complications. This is the largestseries in literature describing the percutaneous closureof these entities.

METHODS

Nine patients with pseudoaneurysms encountered inthe Mayo Clinic Cardiac Catheterization Laboratoryinstitution from April 2003 to February 2011 wereidentified by review of the catheterization lab records.We categorized these based on anatomic location ofthe LV pseudoaneurysm as posterolateral or postero-basal, LV outflow tract, or apical LV pseudoaneur-ysms. Three patients had an ascending aortic pseudoan-eurysm following aortic root replacement. Wereviewed their management and technical strategiesinvolved in percutaneous treatment and outcomes.

Closure Techniques

Coil embolization: Small to moderate-sized pseudoa-neurysms with a narrow neck were deemed suitable forcoil embolization. Most LV pseudoaneurysms wereapproached in a retrograde manner. Access wasobtained via the femoral artery with a 6F sheath.Biplane LV angiography was performed to identify thesize, extent, and the diameter of the neck. Selective an-giography of the pseudoaneurysm was also performedto more accurately define the dimensions of the neck.Coil embolization was then performed by selecting anysuitable guiding or diagnostic catheter engaged into theneck of the aneurysmal sac. The catheter can beadvanced over a glide wire using long 125-cm 5F diag-nostic multipurpose catheter taper. The glide wire canbe exchanged to a 0.035-in. stiff support wire if neededto enter the pseudoaneurysm cavity. Commerciallyavailable embolization coils can then be deployedthrough the guiding catheter to obliterate the cavity.Care should be exercised to avoid extension of thecoils into the left ventricular cavity which could riskembolization. Snares should be available in case re-trieval of embolized coils is necessary.

Septal Occluder Devices

Moderate to large-sized pseudoaneurysms with anarrow neck can be treated with appropriately sizedseptal occluder devices or vascular plug. These can beapproached retrograde or antegrade (transeptal)

depending on the location and accessibility. Access fora retrograde approach through the aortic valve isobtained with a 6F to 8F system. Device sizing isbased on the diameter of the neck of the pseudoaneu-rysm. An appropriate guide catheter or delivery system(typical delivery systems may not be long enoughnecessitating use of coronary guide catheters as a sub-stitute) is selected to engage into the neck of the pseu-doaneurysm. A 6F multipurpose guide catheter with atelescoping 5F long 125-cm multipurpose taper can beused to taper the guide catheter into the aneurysmalsac over a 0.035-in. support wire. The delivery sheathis then carefully guided into the pseudoaneurysm cav-ity. The appropriately selected septal occluder device(AMPLATZER ASD or VSD occluder, AGA, Minne-apolis, MN) can be positioned under transesophagealecho or intracardiac echo guidance across the neck. Af-ter ascertaining (by echo) any possible mechanicaleffects onto adjacent valvular structures, the device canbe deployed with its narrowest diameter across theneck of the pseudoaneurysm. Coronary angiographyduring device deployment can be useful in selectedcases to exclude mechanical compression of the epicar-dial coronary arteries.

CASE DESCRIPTIONS

Percutaneous approaches included coil embolizationor closure with septal occluder devices. The details ofthe cases are shown in Table I. Three patients under-went closure with coil embolization, three with septaloccluder devices, and one patient received no treatmentbut was included as an example of case selectioncriteria.

LV Posterobasal and PosterolateralPseudoaneurysms

Posterior pseudoaneurysms occur more commonlythan anterior pseudoaneurysms, possibly because ante-rior rupture is more likely to result in hemopericardiumand death and posterior rupture is more likely tobecome contained [1]. Posterior pseudoaneurysms canpose a diagnostic challenge, and treatment of these canalso be technically challenging. Cases 1 and 2 illustrateexamples of posterobasal and posterolateral pseudoa-neurysms. Case 1 is a large lobulated posterobasalpseudoaneurysm (Fig. 1A and B) in an 86-year-oldman on chronic anticoagulation. Such a situation posesa therapeutic dilemma. There is a high risk of ruptureand death if these large pseudoaneurysms were leftuntreated [1]. Reoperation was felt to be of prohibitiverisk given the patient’s advanced age and two priorsternotomy incisions. After discussion of the

2 Kumar et al.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

TABLEI.

Summary

ofCaseDescriptionsWithPseudoaneurysmsoftheHeart

Case

Clinical

history

Diagnostic

modalities/ana-

tomic

characteristics

Technique

Technical

success

Complications

Follow-up

1An86y/o

males/predoMVR

andCABG

4/2008,on

chronic

anticoagulationfor

atrial

fibrillation.Essentially

asymptomatic,incidentally

notedlargeposterobasal

LV

pseudoaneurysm

measuring

7�

3cm

2,6�

4cm

2.

TTE/TEE;CT;LVgram

Largelobulatedpostero-

basal

LV

pseudoaneurysm

withneckinferiorandlat-

eral

tomitralannulus.

Thepseudoaneurysm

was

toolargeto

beclosedby

coils.Percutaneousclo-

sure

with22mm

Amplat-

zerseptaloccluder

device.

Yes

Mechanical

compressionof

theCX

bytheoccluder

device(Fig.5)presenting

asventricularfibrillation

—cardiacarrest>24

hours

later.Thiswas

treatedwithPTCA

and

stentingofthedistalCX

withtwolongoverlapping

baremetal

stents

Patienthad

uneventful

recoveryandwas

discharged

onday

10.

2An81yearold

malewithsevere

CAD,priorMIin

1992,

LVEF40%,nopriorcardiac

surgery.Presentedwithchest

pain.Patienthad

Vfibarrest

s/pMI.

Leftventriculogram

revealed

awidemouthed

postero-

lateralpseudoaneurysm

(Figure

9).

Nointerventionto

thepseu-

doaneurysm

was

per-

form

ed

None

None

Patient’shospital

coursewas

complicatedbyanoxic

encephalopathyandsup-

portwas

withdrawn

3A

53-year-old

femalewith

Nativeaortic

valve

Staphylococcusaureus

endocarditiscomplicatedby

extensiveabscessform

ation,

severeaortic

regurgitation,

andem

bolicphenomenon

underwentabioprosthetic

aortic

valvereplacementwith

aortic

rootenlargem

entand

abscessdebridem

ent.

TTEandTEEperform

ed9

dayslatershowed

apseu-

doaneurysm

cavity(m

eas-

uring�

3cm

)anterior

andlateralto

aortic

root,

communicates

withLV

at

thebasal

ventricularsep-

tum.

Treated

withpercutaneous

coilem

bolizationusing

retrogradeapproach.

Yes

None

Did

wellat

follow

up

at38days.

4A

71-year-old

maledeveloped

a

LVOTpseudoaneurysm

followingaortic

hem

iarch

replacementforascending

aortic

dissection.

TTE/TEEandLV

gram

showed

LVOTpseudoan-

eurysm

.

Percutaneousclosure

with

coils

Yes

Afew

coilswerelostinto

thefalselumen

without

clinical

sequelae.

Follow

upechoshowed

an

echofree

space6–12mm

indiameter

withsystolic

flow,closedin

subsequent

echo6monthslater.

5A

78-year-old

man

withaortic

andmitralvalvereplacement

TEE/CTchestandLV

gram

showed

theLVOT

Percutaneousclosure

with

coils

Yes

None

(Continued)

Percutaneous Closure of Pseudoaneurysms 3


Table

I.Summary

ofCaseDescriptionsWithPseudoaneurysmsoftheHeart

(continued)

Case

Clinical

history

Diagnostic

modalities/ana-

tomic

characteristics

Technique

Technical

success

Complications

Follow-up

withbioprosthetic

valves

who

had

incessanthem

olysis

secondaryto

amitral

periprosthetic

regurgitation

was

referred

percutaneous

closure.A

chestCTalso

foundamoderatesized

LVOTpseudoaneurysm

.

pseudoaneurysm

6A

57-year-old

males/preplace-

mentofascendingaortaand

hem

iarchforacute

ascending

aortic

dissectionin

Decem

ber

2008.

MRIrevealed2.3

cmpseu-

doaneurysm

inferolateral

aspectofLV

apex.

Successfulcoilem

bolization

ofthepseudoaneurysm

usingEV3axiom

coils.

Yes

None

Patientdid

wellat

6month

follow

up.Follow-up

CTA

showed

noevidence

ofrecurrence.

7A

59-year-old

males/pBentall

procedure,bypasssurgeryand

previousrepairofaleaking

pseudoaneurysm

offtheprox-

imal

suture

line.

TEEandCTshowed

alarge

lobulatedpseudoaneurysm

withassociated

mass

effect.

Successfulclosure

ofentry

pointwith10mm

ASD

closure

device.

Yes

None

Asymptomatic

8A

59-year-old

man

withprior

CABG

andBentallprocedure

forinfectiveendocarditis

causingsevereaortic

regurgi-

tationandalargeascending

aortic

aneurysm

TEE,ChestCTandaorto-

gram

showed

alarge

pseudoaneurysm

inthe

ascendingaorta

Successfullyclosedtheneck

witha10-m

mAmplatzer

septaloccluder

Yes

None

Mildresidual

flow

into

the

aneurysm

.Majority

ofthe

aneurysm

thrombosedon

follow-upCT

9A

71-year-old

man

withahis-

tory

ofascendingaortic

dis-

section.Theascendingaorta

was

repairedwithaHem

a-

shield

graftandresuspension

ofhisnativeaortic

valve.

One

yearpostprocedure

onrou-

tinesurveillance

chestmag-

netic

resonance

imaginghe

was

notedto

haveamoderate

sizedascendingaortic

pseudo

aneurysm

TEE,MRIandaortogram

revealedthemoderate

sizedascendingaortic

pseudoaneurysm

Successfulclosure

witha

14-m

mAmplatzer

vascu-

larplugII

Yes

None

Doingwellat

2-m

onth

fol-

low

up

4 Kumar et al.


alternatives, it was decided to treat this percutaneously.The technique of percutaneous closure with the 22-mmAMPLATZER Septal Occluder device is shown in Fig.1C and D, with the final result revealing significantreduction in the aneurysmal sac filling. Mitral valvefunction of the bioprosthetic mitral valve was intactfollowing deployment of the device.

Unfortunately, ventricular fibrillation occurredalmost 48 hr after deployment of the device due to me-chanical compression of the distal circumflex coronaryartery (Fig. 2A and B). This was treated with longoverlapping bare metal stents (Fig. 2C and D) with suf-ficient overlap to provide adequate scaffolding and ra-dial strength to withstand external compressive effects.The patient survived. This case highlights the impor-tance of detailed anatomic considerations in planning

percutaneous approaches. The posterobasal location ofthe neck and its proximity to the circumflex increasesthe chances of mechanical compressive effects on thecircumflex artery by these occluder devices. This raisesa similar concern with interventions in this anatomicregion like posterior mitral perivalvular leak closuresand annuloplasty interventions in the coronary sinuswhich could risk mechanical compression of the cir-cumflex artery. It might be reasonable to consider rou-tine coronary angiography during device deployment toassess the mechanical compressive effects. Alternativeadvanced 3D segmentation analysis (Fig. 3) may behelpful in studying the relationship of LV pseudoaneu-rysm to the epicardial structures.

Case 2 is a wide-mouthed posterolateral pseudoaneu-rysm (Fig. 4) which was left untreated. Patient had

Fig. 1. (A) Contrast-enhanced CT showing large multilobu-lated pseudoaneurysm immediately inferior and lateral to themitral prosthesis contained within pericardial sac (yellowarrows) measuring 6.5 3 4.5 cm2 superiorly and 7.0 3 3.2 cm2

inferiorly. The neck (red arrow) just inferior to mitral prosthe-sis measured 15 3 19 mm2. (B) Left ventriculogram showingthe large multilobulated lobulated posterobasal LV pseudoan-

eurysm (arrows) with its neck (yellow arrowhead) inferior andposterior to the mitral annulus. (C) Delivery system in thepseudoaneurysm consisting of Amplatz wire and 8 Fr multi-purpose (MP) guide catheter. (D) Device closure with a 22-mmAMPLATZER Septal Occluder device which was successfullydeployed into the neck of the aneurysmal sac.



cardiac arrest due to ventricular fibrillation and subse-quent anoxic encephalopathy, hence was not a surgicalcandidate. Such wide-mouthed pseudoaneurysms maybe difficult to close percutaneously with an appropriateseptal occluder device. Although percutaneous coilsmight be an option, this can risk embolization or exten-sion of the coils into the true LV cavity.

Depending on their size Amplatzer vascular plugs orvascular coils may be used to close LV posterobasalpseudoaneurysms. Coils are suitable options for treat-ment in small to moderately sized pseudoaneurysmsand in cases where mechanical effects onto adjacentepicardial coronaries or valvular structures are a con-cern.

Left Ventricular Outflow Tract Pseudoaneurysms

LV outflow tract (LVOT) pseudoaneurysms canoccur following aortic valve and aortic root procedures.

Cases 3–5 (Table I) show descriptions of LVOT pseu-doaneurysms that were successfully closed percutane-ously with coil embolization for which AMPLATZERoccluder devices may not be the ideal percutaneousapproach due to extension of the proximal portion ofthe device into the LVOT.

Case 5 involves a 78-year-old man with aortic andmitral valve replacement with bioprosthetic valves whohad incessant hemolysis secondary to a mitral peripros-thetic regurgitation was referred percutaneous closure.A chest CT also found a moderate sized LVOT pseu-doaneurysm. He underwent successful closure of theperiprosthetic mitral regurgitation with an AmplatzerVascular Plug (AVP II) and coil embolization of theLVOT pseudoaneurysm. Figure 5A and B shows theTEE and angiographic images demonstrating a 3-cmLVOT pseudoaneurysm anterior and lateral to the aor-tic root successfully treated with coils (Fig. 5C and D).

Fig. 2. (A,B) Distal CX was completely occluded (arrows) in proximity to the AMPLATZER de-vice (arrow heads). (C,D) reveal PTCA and stenting of the circumflex artery. Long stentedsegment covering areas of moderate disease and provide scaffolding for the kinked distalcircumflex segment adjacent to the occluder device.

6 Kumar et al.


Technical considerations include the anatomic loca-tion and relationship of the pseudoaneurysm to the ad-jacent aortic valve, concomitant valvular abnormalitiesor endocarditis which would require surgical interven-tion and possible mechanical compressive effects bythe pseudoaneurysm onto the epicardial left coronaryartery or left anterior descending artery. Percutaneouscoils are an option for small to moderately sized pseu-doaneurysms in the LV outflow tract, which can beapproached in a retrograde manner.

Left Ventricular Apical Pseudoaneurysm

In contrast to posterior and LVOT pseudoaneurysms,LV apical pseudoaneurysms are relatively easier todiagnose and treat. These can be managed percutane-ously with both coils and occluder devices. There arefewer mechanical concerns on adjacent structures withpercutaneous device deployment for apical LV pseu-doaneurysms. Case 6 illustrates successful coil emboli-zation of an LV apical pseudoaneurysm using detach-able coils (Axium, EV3) (Fig. 6). Depending on thesize of the neck, LV apical aneurysms are amenable toclosure using vascular plugs or coils.

Ascending Aortic Pseudoaneurysm

A large, lobulated recurrent pseudoaneurysmoccurred in a 59-year-old man with prior CABG sur-

gery, Bentall procedure (operation involving compositegraft replacement of the aortic valve, aortic root andascending aorta, with reimplantation of the coronaryarteries into the graft), and emergency repair of a

Fig. 3. (A,B) Three-dimensional reconstruction from CT images for the patient listed as case1 using segmentation with the Analyze software showing the three-dimensional segmenta-tion of the large lobulated pseudoaneurysm and its relationship to the CX (A). This seg-mented anatomy can be separated from adjacent cardiac structures to demonstrate the rela-tive anatomy to selected structures as the CX in this case (B) showing close proximity of theregion of the neck, with no obvious compression (before device deployment).

Fig. 4. Left ventriculogram of patient listed as case 2 with awide-mouthed posterolateral pseudoaneurysm (marked byblock arrow).



leaking pseudoaneurysm (Case 7). Two patent bypassgrafts to the left coronary were present. The defect wascannulated with a hydrophilic 0.035-in guide wire andfollowed with a 5F coronary diagnostic catheter. Thecatheter was exchanged for an 8F hydrophilic Shuttlesheath over a stiff guide wire coiled in the pseudoaneu-rysm and the entry point successfully closed with a 10-mm ASD closure device. The device overlay the leftmain ostium but no ischemia occurred due to the pat-ent grafts.

Case 8 illustrates the occurrence of a large ascend-ing aortic pseudoaneurysm (Fig. 7A and B) in a 59-year-old man with prior CABG and Bentall procedurefor infective endocarditis causing severe aortic regur-gitation and a large ascending aortic aneurysm. Thepseudoaneurysm was cannulated and wired with a 5F

JR 4 diagnostic catheter and an exchange length stiffangled 0.035-in. glide wire. This was then exchangedfor an Amplatz extra stiff wire over which a 7F shut-tle sheath was advanced (Fig. 7C). A 10-mm Amplat-zer septal occluder was then deployed via the shuttlesheath with good results (Fig. 7D), (See onlinevideo).

Case 9 reveals a small to moderate size ascendingaortic pseudoaneurysm that occurred in a 71-year-oldman with a history of ascending aortic dissection. Theascending aorta was repaired with a Hemashield graftand resuspension of his native aortic valve. One yearpostprocedure on routine surveillance chest magneticresonance imaging he was noted to have a moderatesized ascending aortic pseudo aneurysm (Fig. 8A). Thepseudoaneurysm was cannulated with a 5F JR 4

Fig. 5. (A–D) Figure 5A shows transesophageal echo images from case 5 showing LV outflowtract pseudoaneurysm (marked by arrows) anterior and lateral to the aortic root, communi-cating with the LV cavity at the level of basal ventricular septum with systolic flow into theaneurysm which improved after successful coil embolization. Figure 5C shows the LVOTpseudoaneurysm with selective visualization using a Sims2 catheter which was advancedinto the pseudoaneurysm cavity over a glide wire. Figure 5D shows successful coil emboliza-tion into the pseudoaneurysm cavity.

8 Kumar et al.


diagnostic catheter after initial aortic angiography. Anextra stiff Amplatz wire was advanced into the pseudo-aneurysm and the 5F diagnostic catheter wasexchanged for an 8F AR 1 guide catheter. A 14-mmAmplatzer vascular plug II was then deployed with agood fit into the neck of the pseudoaneurysm(Fig. 8B).

Segmentation Analysis

Three-dimensional imaging with CT with addedsegmentation analysis using the Analyze visualizationsoftware [7] (Biomedical Imaging Resource, MayoClinic, Rochester, MN) might be helpful in segment-ing the LV pseudoaneurysm and to study its relativeanatomy for the same patient in case 1 (Fig. 3A andB). Endocardial visualization using these advancedimaging modalities might help to study the dimen-sions of the neck and its relation to the endocardialstructures to guide in device selection and deploy-ment. Volumetric assessment may aid in deciding thevolume of coils required for adequate closure. Visual-izations were created by segmentation of the contrast-enhanced blood pool in the anatomic structures,including the pseudoaneurysm cluster, from the 3Dvolumetric CT data. This is followed by direct vol-ume rendering of the segmented structures from theCT volume, including perspective volume renderingto capture the endocardiac view to study the three-dimensional anatomy of the neck of the pseudoaneu-rysm.

Outcomes

All eight patients treated percutaneously survivedand did well, but the longest follow-up was only 6months. The one patient with the wide-mouthed pseu-doaneurysm who was not treated subsequently arrestedbut had support withdrawn in the setting of anoxicencephalopathy. There was no incidence of stroke ormajor bleeding. One patient had acute myocardial in-farction complicated by ventricular fibrillation second-ary to device occlusion of the left circumflex artery buthe was treated appropriately and made remarkable re-covery.

DISCUSSION

Cardiac and aortic pseudoaneurysms are encounteredrarely in clinical practice. We describe a series of tenconsecutive LV pseudoaneurysm patients who weremanaged percutaneously in a variety of ways.

Indications for Percutaneous Closure Ofpseudoaneurysms

Cardiac and aortic pseudoaneurysms carry a highmortality rate if left untreated [1]; and accordingly,their presence alone is a reason to consider closure.Unfortunately, previous surgical series have reportedsignificant perioperative mortality [1]. Percutaneousclosure with coils or septal occluder devices now offersa feasible alternative to treat these LV pseudoaneur-ysms. A thorough understanding of the three-

Fig. 6. LV gram for case 6 showing the apical pseudoaneurysm successfully embolized with coils.



dimensional anatomy of the pseudoaneurysm and itsrelationship to the epicardial coronary tree and the en-docardial structures (valves) is vital. The size of thepseudoaneurysm and the diameter of the neck are criti-cal features if percutaneous approach is planned. In ourpractice, all patients with pseudoaneurysms arereviewed in a multidisciplinary manner by surgeons

and cardiologists and a consensus decision reached asto the best treatment strategy. In this series, all patientswho had pseudoaneurysms closed percutaneously werejudged high-risk candidates for surgery. The comorbid-ities and the surgical risk of redo sternotomy and redovalve surgery may weigh the decision toward less inva-sive percutaneous approaches. On the other hand,

Fig. 7. (A) MRI showing a large aortic pseudoaneurysm next to the aorta. Figure 7B is 3Dvolume rendered CT image of the large pseudoaneurysm next to the ascending aorta. Figure7C reveals the shuttle sheath and the stiff Amplatz wire in the pseudoaneurysm. Figure 7Dshows the Amplatz vascular plug deployed covering the neck of the pseudoaneurysm.

10 Kumar et al.


concomitant coronary disease or valvular diseaserequiring surgical interventions favor surgical repair insuitable candidates.

Technical Considerations for PercutaneousApproaches

The size of the aneurysm, width of the neck, locationand anatomic relationship to the adjacent epicardial andendocardial structures are important in deciding the typeof percutaneous device (Table II). Coils might be appro-priate in small to moderately sized aneurysms and inaneurysms where mechanical compressive effects due tooccluder devices are a concern. However, precautions toavoid extension into the LV cavity and avoid emboliza-tion are important. In contrast, the factors to consider inchoosing septal occluder devices are the size of the neckand anatomic relationship to the adjacent epicardial andendocardial structures. It is reasonable to consider coro-nary angiography at the time of device deployment.External compression involving the left main and theleft anterior descending due to the pseudoaneurysm orby the occluder devices are important to address in plan-ning closure of LV outflow tract aneurysm. In contrast,structures in the atrioventricular groove (circumflex andthe coronary sinus) are of concern in posterobasal aneur-ysms. Because self-centering occluder size is deter-mined by the central device plug, it is important thatthis dimension for the device reflect the measured neckof the pseudoaneurysm for appropriate device sizing.

Oversized devices remain bulbous and relatively inef-fective occluders.

Coils Versus Occluder Devices—Pros and Cons

The pros and cons of percutaneous coils and septaloccluder devices in treatment of LV pseudoaneurysms

Fig. 8. (A,B): Figure 8A is an aortic root angiogram which reveals the small sized pseudoan-eurysm. Figure 8B show an Amplatzer septal occluder deployed to cover the neck of thepseudoaneurysm.

Fig. 9. Chest CT showing a well placed Amplatzer septaloccluder in the neck of a large ascending aortic pseudoaneu-rysm. Yellow arrow shows the large thrombosed pseudoaneu-rysm, blue arrow shows residual flow within the pseudoaneu-rysm and the red arrow head shows the ASD occluder fillingthe neck of the pseudoaneurysm.



are summarized in Table III. Coils are suitable optionsfor treatment in small to moderately sized pseudoa-neurysms in any anatomic location and where mechani-cal effects onto adjacent epicardial coronaries or valvu-lar structures are a concern. Proper care must be takento avoid extension of the coils into the true lumen. Inappropriately selected patients, septal occluder devicesare suitable options to treat posterobasal or posterolat-eral pseudoaneurysms and apical pseudoaneurysms.Advantages include good technical success withadequate closure with appropriately sized devices rela-tive to the neck of the pseudoaneurysm. Disadvantagesinclude possible mechanical compressive effects ontoadjacent structures. Concurrent coronary angiographyduring device deployment or use of advanced 3Dimaging with segmentation to study the detailed ana-tomic relationship of the neck to the epicardial coro-nary tree might be helpful in avoiding such complica-tions. In addition, since delivery catheters and cablesare relatively stiff, displacement of the delivery systemout of the pseudoaneurysm may occur with attempteddevice deployment. In such instances, smaller deliverysystems and soft, flexible, detachable coils (ev3Axium) may allow easier delivery.

CONCLUSIONS

Percutaneous closure of cardiac and aortic pseudoa-neurysms can be safely performed with good successrates in carefully selected patients in experienced cen-ters. The size, dimensions of the neck and relativeanatomy are important in planning percutaneousapproaches. Routine coronary angiography during de-vice deployment or advanced 3D segmentation analysismight help avoid complications secondary to mechani-cal compressive effects.

ACKNOWLEDGEMENTS

The authors thank Dr. William Edward, Dept. of Pa-thology, Mayo Clinic, Rochester, Minnesota, for his as-sistance with the gross pathologic specimen shown inFig. 7. They also thank the Mayo Biomedical ImagingResource Lab for their assistance with 3D segmenta-tion analysis using the Analyze software.

REFERENCES

1. Frances C, Romero A, Grady D. Left ventricular pseudoaneu-

rysm. J Am Coll Cardiol 1998;32:557–561.

TABLE III. Advantages and Disadvantages of Percutaneous Coils and Septal Occluder Devices in Treatment of CardiacPseudoaneurysms

Coils Septal occluder devices

Technically easier Can be technically challenging

Suitable for small or moderate sized pseudoaneurysms Can be used for even larger pseudoaneurysms

May result in incomplete closure More likely to result in complete closure

Can be used for any anatomic location Careful case selection for posterobasal and LVOT pseudoaneurysms

Mechanical effects are less of concern Mechanical effects onto coronaries or valves are a concern

Not ideal for periprosthetic pseudoaneurysms May be a good choice for periprosthetic pseudoaneurysms especially

if the periprosthetic leak requires concomitant closure.

TABLE II. Technical Considerations for Percutaneous Coils and Occluder Devices in Treatment of Cardiac Pseudoaneurysms

Property of pseudoaneurysm Coils Septal occluder devices Comment

Size of pseudoaneurysm Small to moderate sized Any size

Guide in device selection Volume of pseudoaneurysm Dimensions of neck 3D CT with segmentation analysis

can assist in volumetric assessment

and endocardiac visualization for

3D anatomy of the neck to size

the devices appropriately.

Anatomic location of

pseudoaneurysm

Posterobasal or posterolateral;

LV outflow tract and apical

Apical, posterobasal, or posterolateral

(with precautions to avoid mechanical

effects onto CX)

Relationship to

epicardial coronaries

Less of concern CX in posterobasal or posterolateral

pseudoaneurysms; LM or LAD in

LVOT pseudoaneurysms

Coronary angiography during device

deployment and 3D segmentation

analysis might be helpful to avoid

mechanical complications.

Relationship to valves Less of concern Mitral valve apparatus in posterobasal

or posterolateral pseudoaneurysms;

Aortic valve apparatus in LVOT

pseudoaneurysms

Septal occluder devices may be the

device of choice in

pseudoaneurysms adjacent to

periprosthetic mitral regurgitant

leaks requiring closure.

12 Kumar et al.


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Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms

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