Abstract 4370234: Transcatheter Repair of a Persistent Aortic Root Pseudoaneurysm Using Amplatzer Duct Occluder II and a Covered Stent

Backround: Aortic pseudoaneurysm (PSA) is a rare but life-threatening vascular complication of cardiac surgeries, trauma, and infective endocarditis (IE). It is associated with a high risk of rupture, fistulation, thrombosis, embolization, and erosion into surrounding structures. Surgical treatment remains the standard treatment for aortic PSAs. However, cases with high surgical risk may need alternative options. Case: A man in his mid-70s with a complex cardiovascular history including coronary artery bypass grafting in 2020, treated aortic valve endocarditis in July 2024, and prior surgical patch repair of an aortic root PSA in September 2024, presented to the emergency department with 3 days of epigastric pain radiating to the back with nausea and mild dyspnea. Initial workup ruled out acute coronary syndrome, and CT angiography (CTA) revealed a focal type B aortic dissection and a persistent aortic root PSA measuring 1.5 x 2.2 cm, reduced from 3.0 x 4.6 cm before the patient’s previous surgery. Transesophageal echocardiography (TEE) showed an orifice adjacent to the right coronary cusp. Given the high surgical risk, the multidisciplinary heart team recommended a transfemoral transcatheter approach. The PSA was successfully excluded using an Amplatzer Duct Occluder II device deployed across the neck of the aneurysm, and a Papyrus-covered stent was deployed in the RCA, ensuring complete sealing. The patient had been preloaded with dual antiplatelet therapy (DAPT). The procedure was completed without complication, and the patient remained hemodynamically stable post-operatively. He was discharged on maintenance DAPT, and his post-procedure CT scan after 2 weeks showed exclusion of PSA. Discussion: Management of aortic PSAs is a challenging scenario with high mortality rates with sole medical therapy. Therefore, surgical intervention remains the mainstay of therapy. However, in the setting of high surgical risk, transcatheter approaches have emerged as a viable alternative option. In our case, a novel dual device transcatheter closure technique using a duct occluder, complemented by a covered stent, proved effective in allowing safe exclusion of the PSA while preserving right coronary flow. However, transcatheter closure is not free of potential complications like residual leaks, device migration, incomplete exclusion of the sac, or damage to surrounding structures such as the coronary ostia, and thus, warrants long-term imaging and follow-up in such cases.