A 52-year-old male patient underwent surgical correction of interrupted CoA at the age of 20 years using EABG from the LSCA to the descending aorta. He presented with transient sudden central chest pain with sweating. He is a known smoker for more than 30 years and hypertensive for almost 10 years, on losartan 100 mg once daily. The blood pressure (BP) was 140/90 mmHg, equal in four limbs with no brachiofemoral delay. There was no ischemic electrocardiography (ECG) changes or rise in cardiac biomarkers. His transthoracic echocardiography (TTE) revealed normal left ventricular (LV) function, mild bicuspid aortic valve (BAV) regurgitation, and dilated aortic root. The patient was taken to the cardiac catheterization laboratory and underwent coronary and aortic angiography, which revealed normal coronaries, dilated ascending aorta (3.8 cm), post-ductal aortic interruption, and patent EABG with complex pseudoaneurysm at the distal anastomosis site measuring 2x2.5 cm (Figure ).\nAfter the heart team discussion, endovascular treatment was deemed more feasible and safer than redo-surgery. We implanted two overlapped Valiant Thoracic Stent Graft (Medtronic Vascular, Santa Rosa, CA) proximally 22 mm X 100 mm and distally 28 mm X 100 mm. The aortic angiography revealed complete exclusion of the pseudoaneurysm and patent stent graft with no gradient (Figure ).\nThe patient did very well and was discharged home after two days. A follow-up computed tomographic (CT) angiography revealed a widely patent stent graft with no endoleaks (Figure ).
A 35-year-old man with the diagnosis of mitral atresia, a double outlet right ventricle, pulmonary atresia with interrupted inferior caval vein, and azygous continuation to the right superior caval vein underwent a Blalock-Taussig shunt in early childhood and a Kawashima operation at the age of 17 at another institution. He presented to our clinic with progressive cyanosis and fatigue 18 years after his last surgical procedure. His oxygen saturation was 65%.\nCardiac catheterization revealed left pulmonary artery stenosis and a decompressing vein from the right superior caval vein to the left superior caval vein which directly drains to the left atrium. Left pulmonary artery stenting was done via right internal jugular approach (Figures , , and ).\nHe underwent a second catheterization for occlusion of the left superior caval vein via left internal jugular approach. The anomalous vein measured 22 and 20 mm in AP and lateral projections, respectively. Balloon test occlusion resulted in immediate increase in oxygen saturation from 65% to 82% without drop of blood pressure. The mean pressure in the azygous vein remained at 9 mmHg; pressure in the left internal jugular vein increased to 11 mmHg and dropped within a few minutes to 10 mmHg. Angiography showed good venous collateral drainage.\nThe largest available vascular plug, 24 mm in diameter, failed to completely occlude the vessel, which was successfully occluded using a 24 mm ASD occluder (Cera Lifetech, China) via a 12 Fr sheath. Upon completion of the procedure the patient had oxygen saturation of 80%, left internal jugular pressure of 10 mmHg, and right superior caval vein and pulmonary artery pressure of 9 mmHg.\nAfter occlusion, the patient had significant improvement of his exercise intolerance and fatigue. Follow-up hemodynamic study 12 months later showed no increase in venous pressure, no development of venous collaterals, and no decrease in his oxygen saturation.