Direct Percutaneous Puncture and Embolization of Ruptured Sinus of Valsalva Aneurysm

Excerpt

A 66-year-old man presented to the emergency department with hypotension and sudden-onset chest pain. His only medical history was medication-controlled hypertension. Computed tomography (CT) angiogram demonstrated a 6-cm sinus of Valsalva aneurysm (SVA) arising from the right coronary sinus with rupture into the pericardium (Fig. 1). Transoesophageal echocardiogram (TOE) showed mild aortic regurgitation and good left-ventricular function. Emergency open surgical repair of the aneurysm was undertaken by way of aortotomy using a 4-cm homograft–Hemashield patch (Meadox, Oakland, NJ). Aortic valve replacement was also performed with 27-mm porcine bioprosthesis (St. Jude Medical, St. Paul, MN). Postoperative TOE showed no paraprosthetic leak, but it did reveal sluggish aneurysm refilling, which was considered likely ooze through needle holes in the patch. Follow-up TOE 3 days later showed persistent filling of the aneurysm sac. An endovascular attempt to close the aneurysm was made using an 18-mm Amplatzer cardiac septal occluder (St. Jude Medical). The device was deployed in a satisfactory position, but after the procedure TOE showed continued residual flow into the aneurysm sac. This was confirmed on cardiac gated CT angiogram. At this time, a further endovascular treatment was employed, with placement of 19 0.035-inch pushable embolization coils within the aneurysm sac by way of a left brachial approach. These comprised 13 Azur hydrogel coils (Terumo, Tokyo, Japan) and 6 Nester bare platinum coils (Cook Medical, Bloomington, IN). Three days later, the patient experienced increasing discomfort, and another CT was performed, which again showed persistent leak into the sac. An initial percutaneous injection of 8 ml of human thrombin (GenTrac, Middleton, WI) directly into the aneurysm sac was performed, successfully arresting flow into the sac. One day later, TOE showed thrombosis of the aneurysm sac, with no ongoing symptoms, and the patient was discharged from hospital. Follow-up outpatient CT at 1 month showed increased filling of the aneurysm. Because the patient was considered a poor surgical candidate, it was agreed to carry out a further attempt at percutaneous embolization. The patient gave informed consent. With the patient under local anaesthetic and with CT image guidance, the aneurysm sac was directly punctured with an 18-gauge Chiba needle (Cook) (Fig. 2). Forty-one 0.035 Azur hydrogel coils (Terumo), sizes 15 mm/14 cm, 10 mm/14 cm, and 8 mm/4 cm, along with a further 2 ml of human thrombin, were injected into the aneurysm sac. Postprocedure cardiac gated CT angiography showed complete thrombosis of the aneurysm sac with no evidence of ongoing filling (Fig. 3). Follow-up transthoracic ultrasound at 6 and 12 months confirmed complete occlusion of the sac.

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