Endovascular repair of ascending aortic pseudoaneurysm: Technical considerations of a common carotid artery approach using the Zenith aortic cuff endograft

Purpose: To present a technique for endovascular treatment using Zenith aortic cuff extenders delivered via a left common carotid artery (CCA) approach in a patient with a large symptomatic ascending aortic pseudoaneurysm. Case Report: A 78-year-old man with recent stroke developed worsening exertional dyspnea and chest pain 4 years following coronary artery bypass grafting. Imaging demonstrated a bovine arch and an 8- x 12-cm ascending aortic pseudoaneurysm that was compressing the pulmonary arteries. The treatment strategy was to deliver a Zenith aortic cuff to seal the ascending aortic pseudoaneurysm via a left CCA approach. With the patient under general anesthesia, the left CCA was exposed and a transverse arteriotomy was made to introduce the Zenith aortic cuff sheath; the distal CCA was clamped to prevent catheter-related embolization. With its nosecone removed, a 32- x 36-mm Zenith aortic cuff was delivered to the ascending aorta via the left CCA and positioned under transient cardiac arrest initiated with intravenous adenosine. A total of 3 Zenith aortic cuffs were placed in the ascending aorta to successfully exclude the pseudoaneurysm. The patient tolerated the procedure well; follow-up imaging showed successful pseudoaneurysm exclusion without endoleak. Conclusion: Ascending aortic pseudoaneurysm is a formidable clinical challenge due in part to the significant operative stress in a conventional surgical repair, as well as limited endovascular treatment options. Because there are no approved endovascular devices for ascending aortic aneurysm repair, clinicians may have to rely on endograft components designed for abdominal aortic aneurysms to treat lesions in the ascending aorta.