Successful endovascular repair of an aneurysm of the ductus diverticulum with a branched stent graft: Case report and review of literature

Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease

Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.

Incidentally identified ductus arteriosus aneurysm in eight adults: a case series

Ductus arteriosus aneurysm (DAA) in adulthood is a rare entity. We retrospectively reviewed our medical records from the past 10 years and identified 8 cases of adult DAA (6 males and 2 females aged between 69 and 89 years; mean, 76 years), using multiplanar reconstruction and three-dimensional reconstruction CT images. The aneurysm was suspected incidentally in all cases based on the results of chest radiographic screening or post-operative follow-up CT for lung or colon cancer. All eight patients were asymptomatic but had a history of or concurrent hypertension (n = 5, 62.5%), diabetes mellitus (n = 3, 37.5%), cerebrovascular disease (n = 3, 37.5%), ischemic heart disease (n = 1, 12.5%), and cardiac failure (n = 1). All patients had no history of trauma (n = 8, 100%). Six had a history of cigarette smoking. The aneurysm size ranged from 2.0 × 4.0 to 6.3 × 5.3 cm (mean, 3 × 5 cm). The surgical procedures used were four cases of total arch replacement and two cases of thoracic endovascular aortic repair. Two patients were not surgically treated. The median follow-up was 14.5 months (range, 2 months to 9 years). In the two patients who were not surgically treated, the aneurysm enlarged in one, and remained unchanged in the other. Of the six surgically managed cases, one was lost to follow-up, and another patient died of an unrelated cause. The remaining four cases had no enlargement of the aneurysm. No ruptures were reported in any of the cases. DAA should be considered when a saccular aneurysm is located in the minor curvature of the aortic arch and extending toward the left pulmonary trunk in adult patients. Differentiating adult DAA is important, because it is associated with a high risk of rupture due to the fragile nature of true aneurysms.

Use of stent-grafts for the ductus arteriosus and its related lesions

Five cases of ductal lesions with various anatomies have been successfully treated by thoracic endovascular aortic replacement in recent years; 4 using mainly fenestrated stent-grafts, and one using a non-fenestrated stent-graft. Considering the invasive nature of open surgery and the anatomical limitations of the catheter technique for occluding a patent ductus in many adult cases, thoracic endovascular aortic replacement should be the first option because of its broad applicability for ductal lesions.

Ductus arteriosus aneurysm presenting as hoarseness: successful repair with an endovascular approach

An aneurysm of the ductus arteriosus is a rare finding, particularly in the adult population. These saccular aneurysms arise at the site of an incompletely obliterated ductus arteriosus along the lesser curvature of the aortic arch. Left untreated, it is associated with a high risk of potentially life-threatening complications including rupture, infection and thromboembolism. As a result, surgical correction is recommended. Previously, options were limited to open repair but as endovascular experience grows, novel techniques afford safer and less invasive alternatives. In contrast, neonatal ductus arteriosus aneurysms may regress spontaneously and expectant treatment can be justified. We present the case of a 74-year-old woman who presented with hoarseness secondary to a ductus arteriosus aneurysm; a diagnosis consistent with Ortner's syndrome. The patient underwent an uncomplicated endovascular repair using the chimney-graft technique.

A hybrid open and endovascular repair for treatment of bovine aortic arch aneurysm accompanied by aneurysm of patent ductus arteriosus with deployment of Amplatzer duct occluder

A rare case of bovine aortic arch aneurysm accompanied by patent ductus Botalli aneurysm was treated using an off-pump hybrid procedure including supraaortic debranching combined with aortic stent grafting and oversewing of pulmonary artery end of the aneurysm. Postoperative computed tomography angiography showed persistent perfusion of the ductus Botalli aneurysm from pulmonary artery, which was successfully closed with an Amplatzer duct occluder. Twenty-two months of follow-up showed good general state of the patient's health status. This less invasive procedure is an alternative to aortic replacement under circulatory arrest and may be the only salvage option for patients in poor general condition.

Endovascular repair of an ductus arteriosus aneurysm causing Ortner syndrome

A ductus arteriosus aneurysm (DAA) is a rare but potentially fatal condition in adults. In the past, open surgery was the only available option for treatment. Nowadays, endovascular repair has emerged as a safe and less invasive treatment option for aortic aneurysms. However, there is little experience with DAA and its anatomic location can complicate endovascular repair. Here, we describe the case of a 69-year-old patient who presented with Ortner syndrome caused by DAA, which was successfully treated using a solely endovascular approach and a standard stent graft.

Treatment paradigms for ductus arteriosus aneurysms in adults

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature.

Endovascular repair of the aortic arch in pigs by improved double-branched stent grafts

INTRODUCTION

This study aimed to evaluate the feasibility of total endovascular repair of the aortic arch in pigs using improved integrated double-branched stent grafts.

METHODS

Improved self-expandable stent grafts with a main body and two integrated branches were prepared for the repair of the aortic arch in six pigs. The feasibility of using these stent grafts was evaluated with arteriography, computed tomography (CT), computed tomography angiography (CTA) and autopsy three months following the procedure.

RESULTS

The double-branched stent grafts were placed successfully in the aortic arch in all six pigs. All pigs survived for at least three months and their biological behaviour was normal. Arteriography, CTA and animal necropsy revealed good fixation in all cases. Aortic valve function and coronary ostia remained intact, and CT of the head did not detect any lesion of cerebral infarction.

CONCLUSIONS

Endovascular repair of the aortic arch with an integrated double-branched stent graft is safe and feasible in animal studies.

Perfect and least invasive sealing technique on the lesser curvature of the aortic arch: application of a novel stent graft to an aneurysm developing on a postoperative ductus arteriosus

A 78-year-old woman who underwent an operation for a patent ductus arteriosus (PDA) about thirty years ago developed an aneurysm on the aortic side of the remnant ductal tissue. To avoid risky, open surgery, we performed endovascular aortic therapy using a novel stent graft (SG), which was pre-curved, fenestrated and custom-made type. This graft was designed to configure to the patient's whole aortic arch anatomy, and was capable of accurately adjusting its fenestrations to the arch branch orifices during the procedure. The operation was successful, and the patient was discharged uneventfully on 16th postoperative day. The advantage of this fenestrated SG is close sealing, especially over the lesser curvature of the arch. This device could be a simple and effective option to deal with an otherwise normal aortic arch with such a ductus-related localized lesion.

An innovative exclusion technique for ductus arteriosus with a novel stent graft

A 72-year-old woman who had a patent ductus arteriosus that was anatomically unsuitable for catheter coiling was treated with a pre-curved fenestrated stent graft. This graft was custom-made to configure the patient's whole aortic arch, and was capable of accurately adjusting its fenestrations to the arch branch orifices. The advantage of this fenestrated stent graft is close sealing, especially on the lesser curvature of the arch. This device could be an excellent option to treat an otherwise normal aortic arch with such a localized lesion.

Endovascular repair of the half aortic arch in pigs with an improved, single-branched stent graft system for the brachiocephalic trunk

The objective of this study was to evaluate the feasibility of endovascular repair of half of the aortic arch in pigs using an improved, integrated, single-branched stent graft for the ascending aorta and brachiocephalic trunk (BCT). We designed an improved stent graft in an integrated fashion and deployed the stent grafts into the ascending aortas and BCT of eight pigs. The feasibility of the stent graft deployments was evaluated three months after the procedures using arteriography, computed tomography angiography (CTA) and animal autopsy. The stent grafts were successfully deployed in eight pigs. All animals survived for at least three months. Arteriography, CTA and animal necropsy revealed good stent fixation in eight cases. Their head CT scans found no evidence of cerebral infarction. In conclusion, endovascular repair of the half aortic arch with the integrated single-branched stent graft system appears to be safe and feasible in pigs.

Total arch replacement with open stent-grafting for aneurysm of ductus arteriosus after surgery for patent ductus arteriosus

A 73-year-old woman who had undergone ligation of patent ductus arteriosus (PDA) via a left thoracotomy 19 years earlier was admitted to our hospital under the diagnosis of thoracic aortic aneurysm. An enhanced computed tomography of the chest revealed a saccular aneurysm measuring a maximum diameter of 28 mm in the lesser curvature of the distal aortic arch; she was diagnosed with an aneurysm of ductus arteriosus after surgery for PDA. We performed total aortic arch replacement with open stent-grafting through median sternotomy. This approach enabled us to avoid the risk of dissecting adhesions around the aneurysm and clamping the aorta distal to the aneurysm. 

Incidental detection of a giant ductus arteriosus aneurysm by low-dose multidetector computed tomography in an asymptomatic adult

Aneurysm of the ductus arteriosus is a very rare congenital lesion in adults that can be associated with thromboembolism, rupture, and death. Its detection in a silent clinical phase is very important for planning appropriate treatment and avoiding potentially fatal complications. We report a case of a patent ductus arteriosus aneurysm of very large size (65.5 mm) that was incidentally discovered with low-dose (3.2 mSv) multidetector computed tomography in an asymptomatic 67-year-old man. The presence of coronary disease was also ruled out with this non-invasive imaging modality. Further evaluation with echocardiography and selective angiography confirmed the diagnosis. At surgery, the aneurysm was successfully resected via a left posterolateral thoracotomy.