Transient Recurrent Laryngeal Nerve Palsy after Interventional Therapy

BACKGROUND

 Hoarseness due to laryngeal nerve injury is a known complication after cardiothoracic surgery involving the aortic arch. However, this complication is only rarely reported after catheter interventions.

RESULTS

 In this article we present the unusual case of a left-sided vocal cord paralysis in four patients after primary stenting of a re-coarctation, re-dilatation of a stented coarctation, a primary stenting of the left pulmonary artery (LPA), and prestenting for percutaneous pulmonary valve implantation with dilation of the LPA. After implanting bare metal stents, it is common practice, whilst contemplating the diameters of the adjacent structures, to optimize the stent diameter in a two-step procedure and dilate the stent until a maximum diameter is achieved and there is no residual gradient after applying this technique. Four of our patients experienced hoarseness after the intervention and a vocal cord paralysis was diagnosed. Angiography revealed no signs of extravasation or dissection. Clinical symptoms improved over the course of the following 6 months; patients with interventions at the aortic arch showed a complete remission, patients with procedures involving the LPA showed only mild regression of the symptoms.

CONCLUSION

 To our knowledge, this complication (Ortner's syndrome, cardiovocal syndrome) after such interventions has rarely been reported before. Although a rare complication, the recognition of these symptoms may support colleagues in managing affected patients. In addition, awareness for hoarseness after interventional therapies and systematic screening for this complication might help to identify patients at risk in the future.

Hybrid Surgical Approach to a Giant Post-Coarctation Aortic Aneurysm

PURPOSE

To report a rare case of giant aortic coarctation (CoA)-related descending thoracic aneurysmal degeneration, complicated by an acute aortic dissection.

CASE REPORT

A 57-year-old man referred with acute chest pain to the emergency department. A computed tomography angiography (CTA) revealed a CoA with a giant post-stenotic descending thoracic aneurysm (14 cm) and a concomitant left subclavian artery (LSA) aneurysm, complicated by an acute type B aortic dissection. A single-stage hybrid procedure was planned in an urgent setting. Initially, a left common carotid-to-left subclavian artery (LCCA-LSA) bypass was performed to gain a suitable proximal landing zone, the procedure was then completed with 3 thoracic endografts and 1 aortic dissection stent through a percutaneous femoral approach. The patient was discharged in postoperative day 8th without complications; the CTA performed at 1 month demonstrated patency of supra-aortic and visceral vessels, dilation of CoA site and exclusion of the false lumen.

CONCLUSIONS

CoA is a congenital malformation rarely found in adults that may represent a challenge for the surgeon, especially when combined with a complication like an acute aortic dissection. This case shows that a hybrid approach is a safe and feasible treatment option even in such complex anatomies.

Saccular "Cauliflower" aneurysm of coarctation of aorta: a hybrid management

Aneurysm formation around the site of coarctation of aortic arch is a well-recognised complication of untreated coarctation and is associated with an increased risk of aortic rupture and mortality. We present a rare case in a teenage girl with the combination of significant aortic arch coarctation, a "cauliflower-like" saccular aneurysm, and stenosis at the origin of the left subclavian artery. She was successfully managed with a hybrid approach, which is a combination of an endovascular surgical repair (a bypass graft placement from left carotid artery to subclavian artery by a vascular surgeon) and a transcatheter covered stent placement across the stenosis and aneurysm. This case highlights the successful role of a hybrid approach in patient's who present with a combination of coarctation of the aorta and aortic arch aneurysms. This approach avoids the conventional surgical aortoplasty, which carries a higher mortality and morbidity risk in teenage patients.

Endovascular management of a rare complication of an aortic coarctation

A 28-year-old pregnant woman presents with arterial hypertension of the upper limbs. The examination suggests an aortic coarctation. After a normal delivery, a contrast-enhanced computed tomography revealed a subocclusive aortic coarctation of the descending thoracic aorta and a 33-mm aneurysm developed from the left cervical-thoracic artery. The coarctation of the aorta was treated by a stent graft, and the aneurysm was treated by an injection of thrombin and glue.

Coarctation repair-redo challenges in the adults: what to do?

Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.

Endovascular Treatment of Distal Aortic Arch Aneurysm Associated with Coarctation of Aorta in a Jehovah's Witness

Late aneurysm formation in the proximal aorta or distal aortic arch is a recognized sequela of untreated stenosis of the aortic isthmus and is associated with substantial risk of aortic rupture. We describe the case of a 44-year-old man with untreated coarctation of the aorta who presented with a prestenotic dissecting thoracic aortic aneurysm. He declined surgery because he was a Jehovah's Witness. Instead, we performed emergency endovascular aortic repair in which 2 stent-grafts were placed in the descending aorta. Our experience suggests that this procedure is a useful and safe alternative to open surgery in patients who have aneurysms associated with coarctation of the aorta.

Case Report: An Innovative Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm following an Open Coarctation Repair

It was once postulated that open surgical repair of coarctation of the aorta during childhood patients was cured. However, long-term follow-up has been significant for late problems such as an aneurysm. The incidence of such aneurysm after open surgical coarctation repair is 11-24%. If such an aneurysm is left untreated, patients are at a high risk of morbidity and mortality. Prior to the endovascular era, patients would require a redo open repair which in itself is a highly morbid operation. Currently, thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical reprocedures in this context. However, TEVAR might be challenging due to the proximity of the pathology to supraaortic vessels and the ongoing presence of the coarctation. We are reporting a unique case of a 48-year-old male undergoing TEVAR due to aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm After Coarctation Operation

The incidence of aneurysm after open surgical repair of coarctation is 11% to 24%. If the condition is left untreated, fatal rupture may occur. Thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical repeated procedures in this context. However, TEVAR might be challenging because of the proximity of the pathologic condition to the supraaortic vessels and the ongoing presence of the coarctation. We report a unique case of a 48-year old man undergoing TEVAR because of aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

The Ascending Aorta as an Exit Site for a Through-and-Through Wire in TEVAR

PURPOSE

To describe a technique for trans-ascending aorta through-and-through guidewire placement for thoracic endograft advancement and deployment.

CASE REPORT

A 55-year-old man presented with a symptomatic pseudoaneurysm of the distal aortic arch after aortic coarctation open repair. He had also undergone mechanical aortic valve replacement. Planned were a left-sided carotid-subclavian bypass and a thoracic endovascular aortic repair with a chimney graft to the left common carotid artery. After carotid-subclavian bypass, efforts to retrograde cannulate the aortic arch and advance the thoracic endograft were unsuccessful. Because of the mechanical heart valve, no transapical approach could be used. Access to the ascending aorta was gained through a midline sternotomy. A through-and-through wire was positioned from the ascending aorta to femoral artery, which provided the required stability for advancement of the thoracic endograft. Six-month computed tomography documented patent endografts and carotid-subclavian bypass and no evidence of endoleak.

CONCLUSION

A trans-ascending aorta through-and-through guidewire is a feasible adjunct that can be added to the endovascular armamentarium when transcardiac or transbrachial approaches are impossible or ineffective.

Coarctation of the Aorta: Strategies for Improving Outcomes

Coarctation of the aorta is a common congenital heart defect through which management has rapidly evolved over the last few decades. The role of transcatheter-based therapies is expanding and seems to be an effective treatment option for coarctation, especially in adults. Patients with prior coarctation repair are at risk of long-term complications related to prior surgeries and associated congenital heart defects, in particular, the risk of restenosis and aortic aneurysm development related to the timing and mode of prior intervention. This article outlines the evaluation and management of adults with unrepaired coarctation and patients after coarctation repair.

Late complication after repair of aortic coarctation

Background

Coarctation of the aorta is a congenital malformation that has long been considered completely correctable with appropriate surgery in childhood. However, with the aging of these patients, many late complications have been reported, and this notion must be reevaluated.

Methods

We retrospectively reviewed all patients who underwent reoperation between 1992 and 2012 in our adult cardiac surgery department following surgical correction of coarctation in childhood; 18 patients over 15-years old were included in the study.

Results

The median time from coarctation repair to reoperation was 25 years. Patients were reoperated on for several late complications: aortic valve disease secondary to bicuspid aortic valve, ascending aortic aneurysm, recoarctation, aortic arch hypoplasia, pseudoaneurysm, associated recoarctation and pseudoaneurysm, subvalvular aortic obstruction, and descending thoracic aortic aneurysm. One patient died due to an intraoperative complication. In the other cases, the surgical results were satisfactory at the 6-month follow-up. According to literature data, age at coarctation repair and surgical technique appear to be essential factors in late complications: older age and surgical repair with prosthesis interposition are associated with a higher rate of reintervention.

Conclusion

Patients who have undergone repair of aortic coarctation frequently remain asymptomatic for a long time. Late complications can be appropriately treated when diagnosed early. Consequently, all coarctation patients need careful lifelong follow-up, especially those with congenital aortic valve disease or surgery in childhood with interposition of prosthetic material.

Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair

OBJECTIVE

Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival.

METHODS

Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival.

RESULTS

Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)].

CONCLUSIONS

SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific.