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Images and Case Reports in Heart Failure
Endovascular Stent Grafting of a Left Ventricular Assist
Device Outflow Graft Pseudoaneurysm
Asvin M. Ganapathi, MD; Nicholas D. Andersen, MD; Deyanira J. Prastein, MD;
Zubair A. Hashmi, MD; Joseph G. Rogers, MD; Carmelo A. Milano, MD;
Richard L. McCann, MD; G. Chad Hughes, MD
A
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61-year-old female underwent implantation of a
Heartmate II left ventricular assist device (LVAD;
Thoratec Corporation, Pleasanton, CA) for end-stage nonischemic cardiomyopathy. Six months later, she presented with
chest pain and worsening heart failure symptoms. Computed
tomography angiography revealed a large subxiphoid pseudoaneurysm with peripheral thrombus exerting a mass effect
on the heart (Figures 1 and 2). Further evaluation by ultrasonography with anterior chest transducer placement confirmed
a 13-cm pseudoaneurysm with multiple connections to the
LVAD outflow Dacron graft (Figure 3). She was afebrile and
had no physical or laboratory evidence of infection. Because
of extensive comorbidities, including morbid obesity, restrictive lung disease, and chronic renal insufficiency, open repair
via repeat sternotomy was considered risk-prohibitive, and an
endovascular repair was pursued.
Off-label use of a Gore Excluder (W.L. Gore and Associates,
Flagstaff, AZ) iliac limb stent graft (16 mm proximal diameter, 18 mm distal diameter×9.5 cm length) was considered
the best commercially available device to attempt endovascular repair. This device was chosen because of the appropriate
size match to the Dacron LVAD outflow graft and the short
nose of the delivery catheter, which would permit advancement close to the LVAD pump mechanism. Because of a
delivery catheter shaft length of only 55 cm, a left axillary
artery approach was chosen for device delivery. The left axillary artery was exposed via an infraclavicular incision. An 8
mm Dacron conduit was sewn end-to-side to this artery and
brought out through a separate stab incision on the lateral
chest to minimize the angle of entry for the wires and sheaths,
given patient obesity. Initial attempts at retrograde entry into
the LVAD outflow tract from the ascending aorta proved difficult because of high LVAD flow. As such, the decision was
Figure 1. Axial computed tomography angiography image
­demonstrating the large subxiphoid pseudoaneurysm (red
arrow) with area of communication to the outflow graft of the
left ­ventricular assist device (LVAD; yellow arrow).
Figure 2. Three-dimensional computed tomography angiography
reconstruction demonstrating pseudoaneurysm (yellow arrow)
arising from the outflow graft (blue arrow) of the left ventricular
assist device (LVAD; red arrow).
Received September 5, 2012; accepted November 6, 2012.
From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular
Surgery (R.L.M.), Duke University Medical Center, Durham, NC.
Correspondence to G. Chad Hughes, MD, Director, Aortic Surgery Program, Duke University Medical Center, Division of Cardiovascular and Thoracic
Surgery, Box 3051, Durham, NC 27710. E-mail [email protected]
(Circ Heart Fail. 2013;6:e16-e18.)
© 2013 American Heart Association, Inc.
Circ Heart Fail is available at http://circheartfailure.ahajournals.org
e16
DOI: 10.1161/CIRCHEARTFAILURE.112.971861
Ganapathi et al LVAD Outflow Tract Pseudoaneurysm Repair e17
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Figure 4. A, Initial angiography run demonstrating the large
pseudoaneurysm (red arrow) at the base of the outflow graft
(yellow arrow; ascending aorta indicated by green arrow).
B, Fluoroscopy demonstrating wires (yellow arrow) in the left
ventricular assist device (LVAD) outflow graft extending into the
LVAD apparatus (red arrow). C, Early image of completion angiography run demonstrating contrast in the upper part of LVAD
outflow graft within the newly placed endograft (blue arrow). D,
Later image of completion run demonstrating good flow through
the endograft (yellow arrow) and absence of the blush seen previously within the pseudoaneurysm (red arrow).
Figure 3. A, Sagittal ultrasonographic view of the anterior chest
demonstrating a 13×9 cm fluid collection (demarcated by + symbols) surrounding the outflow tract (red arrow) from the left ventricular apex (yellow arrow) to the left ventricular assist device
(LVAD). B, Sagittal Doppler view demonstrating swirling flow
within the fluid collection consistent with pseudoaneurysm.
made to temporarily turn off the LVAD, after full systemic
heparinization to an activated clotting time of greater than
300, which the patient tolerated hemodynamically. An arteriogram of the ascending aorta/arch was then performed, and
the location of the distal anastomosis of the LVAD outflow
graft identified (Figure 4A) and successfully cannulated using
a Cobra-2 catheter (AngioDynamics, Latham, NY), followed
by an Amplatz superstiff wire with a 1-cm floppy tip (Cook
Medical, Bloomington, IN) that passed into the LVAD outflow graft and down to above the pump portion of the LVAD.
An 18-French Gore dry-seal sheath was passed into the LVAD
outflow graft over the stiff wire, and a subsequent arteriogram
revealed the pseudoaneurysm in the proximal portion of the
LVAD outflow graft above the elbow portion of the LVAD
(Figure 4A and 4B). The endograft was then deployed with
3 to 4 cm of seal both above and below the location of the
­pseudoaneurysm. Balloon molding was accomplished with
a 16 mm×4 cm angioplasty balloon, and a completion arteriogram demonstrated complete exclusion of the pseudoaneurysm and a well-expanded endograft (Figure 4C and 4D),
after which the LVAD was restarted (total LVAD pause time
22 minutes). The patient tolerated the procedure well and
was discharged home after treatment of her heart failure
exacerbation. Follow-up imaging 6 weeks later demonstrated
a well-positioned stent graft without evidence of endoleak
and complete resolution of the pseudoaneurysm (Figure 5A
through 5C). The patient remains well 10 months postendovascular repair.
Discussion
Pseudoaneurysms associated with LVADs are rare, with prior
reports of occurrence at the left ventricular apex, as well as
the anastamosis of the outflow graft to the ascending aorta.1
Pseudoaneurysm of the LVAD outflow graft, thought to be
secondary to graft contact with a sternal wire causing erosion
of the graft, was reported in a patient with a Novacor N100
LVAD; this pseudoaneurysm required open repair under deep
hypothermia and circulatory arrest.2 Additionally, endovascular repair of a fistula between the outflow graft of a Heartmate
II and a portion of the right bronchial tree, with access from
the right common carotid artery, has been described.3
In the present case, pseudoaneurysm formation could have
resulted from prosthetic graft damage during implantation
or contact with the sternal wires, as previously described.
Additionally, detachment of the bend relief device (Figure
6), which overlies the LVAD outflow graft, could have caused
outflow graft damage and pseudoaneurysm formation. To this
latter possibility, a recent FDA warning was issued regarding
concerns of the bend relief device causing graft obstruction
and detachment from the LVAD.4 The endovascular repair
strategy described herein represents the second placement
e18 Circ Heart Fail January 2013
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Figure 6. Image of Thoratec Heartmate II system (http://www.
thoratec.com/img/content/sealed-graft-sm.jpg) altered with black
arrow to indicate bend relief device. Reprinted with the permission of Thoratec Corporation.
Lifelong surveillance follow-up imaging is therefore recommended, similar to other endovascular repair procedures.
Nonetheless, the endovascular strategy presented seems to
represent a novel, safe, and effective treatment for LVAD outflow tract pseudoaneurysm that avoids a highly morbid open
operation in a compromised patient population.
Sources of Funding
Salary support was provided by a Thoracic Surgery Foundation for
Research and Education Research Fellowship (to N.D.A.).
Disclosures
Dr Hughes is a paid consultant for W.L. Gore and Associates and
Terumo Medical. Dr Milano is a paid consultant for Thoratec
Corporation. Dr Rogers is a paid consultant for Thoratec Corporation.
Figure 5. A, Three-dimensional computed tomography angiography reconstruction image demonstrating the endovascular stent
graft in the left ventricular assist device (LVAD) outflow graft. B,
Axial computed tomography angiography image showing successful endovascular exclusion of the pseudoaneurysm with no
evidence of endoleak. C, Sagittal computed tomography angiography reconstruction image demonstrating the endovascular
stent graft in the LVAD outflow graft.
of an endovascular stent graft within an LVAD circuit, and
the first endovascular repair of an LVAD outflow graft pseudoaneurysm to our knowledge. Potential complications of
this repair strategy include endograft infection, potential for
LVAD-related thrombus, especially given the temporary cessation of device flow (albeit during a period of full systemic
heparinization), damage to the pump mechanism from catheters or wires, wire or catheter entrapment, and endoleak.
References
1. Maeda T, Tanoue Y, Nakashima A, Tominaga R. Atypical presentation of
an apical pseudoaneurysm in a patient on prolonged left ventricular mechanical support. Interact Cardiovasc Thorac Surg. 2010;10:350–351.
2. Knosalla C, Weng Y, Buz S, Loebe M, Hetzer R. Pseudoaneurysm of the
outflow graft in a patient with Novacor N100 LVAD system. Ann Thorac
Surg. 2000;69:1594–1596.
3. Yanagida R, Kass R, Czer L, Khoynezhad A. Endovascular repair of arterio-bronchial fistula of the outflow graft of HeartMate II left ventricular
assist device. J Thorac Cardiovasc Surg. 2011;142:710–711.
4. U.S. Food and Drug Administration. Thoratec Corporation, HeartMate
II Left Ventricular Assist System (LVAS): Class 1 Recall-Outflow Graft
May Kink or Deform. U.S. Food and Drug Administration. April 4, 2012.
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm298710.htm. Accessed July 6, 2012.
Key Words: aneurysm ◼ cardiomyopathy ◼ ventricular assist device
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Endovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft
Pseudoaneurysm
Asvin M. Ganapathi, Nicholas D. Andersen, Deyanira J. Prastein, Zubair A. Hashmi, Joseph G.
Rogers, Carmelo A. Milano, Richard L. McCann and G. Chad Hughes
Circ Heart Fail. 2013;6:e16-e18
doi: 10.1161/CIRCHEARTFAILURE.112.971861
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