Endovascular treatment of an anastomotic outflow graft pseudoaneurysm of the descending aorta after implantation of a left ventricular assist device

Introduction: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after the implantation of the left ventricular assist device (LVAD).


| INTRODUCTION
The outflow graft (OG) of left ventricular assist devices (LVAD) is usually anastomosed to the ascending aorta, but occasionally also to the descending aorta or its major branch. 1 Pseudoaneurysm formation of the vascular anastomosis is infrequently reported and may in some cases lead to OG obstruction causing heart failure, which may be treated by means of an intervention. [2][3][4] We describe, for the first time, an obstruction of the OG due to a pseudoaneurysm of the OG anastomosis to the descending aorta. To prevent rupture of the pseudoaneurysm and further obstruction of the OG, a customized fenestrated stent graft was implanted into the descending aorta, followed by OG stenting.

| CASE REPORT
A 67-year-old male with ischemic cardiomyopathy (history of CABG 8 years ago) was admitted due to a significant deterioration in his physical condition, 2 years after implantation of an LVAD (Heart-Ware HVAD; Medtronic, Minneapolis, MN) with the OG placed into the descending aorta (due to adhesions following prior CABG surgery). The LVAD implantation was performed as destination therapy.
During the diagnostic evaluation, the computed tomography angiography (CTA) showed a leak in the OG anastomosis, which had re- F I G U R E 2 Stent preparation. A, E-vita Thoracic 3G 30 × 100-mm stent is exposed halfway from its deployment system; a 9-mm hole is cut into the wall. B, A tip of a flexible radiopaque guidewire was sewed around the aperture using 5-0 Prolene sutures. C, Completed 9-mm window with radiopaque ring. D, Fluoroscopy outside the body showing the position of the aperture in the stent (red arrow) E-ventus 37 × 10-mm peripheral stent graft (both Jotec, Hechingen, Germany) were selected. In a first step, which was performed under sterile conditions on the back table, the thoracic stent graft was pulled halfway out of its deployment system and a 9-mm hole was cut into the middle segment. To make the aperture visible under fluoroscopy, the X-ray visible tip of a flexible guidewire was sewed around the hole using 5-0 Prolene sutures (Figure 2). The stent was then reinserted and irrigated with the antibiotic solution through the lumen of the deployment system.
In the next step, the thoracic stent was advanced into the descending aorta using a Super Stiff guidewire via percutaneous access in the right femoral artery. The stent was expanded halfway and the created window was positioned facing the OG anastomosis.
The right axillary artery was surgically exposed and an introducer | 3197 pseudoaneurysm was caused by minimal anastomotic insufficiency with subsequent bleeding under the adventitia. However, such a constellation is difficult to identify during surgery.
In our unusual case, an interventional approach with a fenestrated stent graft and placement of a stent branch into the OG was shown to be safe and effective. However, an infectious cause of the pseudoaneurysm formation should be ruled out by means of a clinical examination and PET-CT. In such a case, surgical replacement of the descending aorta by a homograft should be considered instead.

| CONCLUSION
In cases of LVAD OG obstruction due to a pseudoaneurysm formation, an endovascular approach to restore optimal blood flow is an effective alternative to surgery.