A 54-year-old male patient with long standing history of type II DM, dyslipidemia and hypertension, with medical therapy of bisoprolol 10 mg daily, valsartan 160 mg daily, HCTZ 25 mg daily, atorvastatin 20 mg nocturnally, insulin and metformin was admitted to a peripheral hospital with bronchopneumonia requiring high dependency unit admission. This was complicated by a transient ischemic attack. Brain computed tomography (CT) was normal. On the second day of admission, he had a significant episode of chest pain. Electrocardiogram (ECG) showed transient ST-segment elevation with spontaneous resolution in the inferior lead. There was mild troponin leak. He was later referred to our center for further workup. His physical exam revealed oxygen saturation at 98% on room air, pulse 70 bpm, BP both upper limb 155/65 mm Hg, and BP lower limb 105/45 mm Hg. There was a brachio-femoral delay. Apex was mildly displaced; he had S1+ S2+ S4 and a systolic murmur at the tip of left scapula; no clicks were appreciated on auscultation.\nECG showed sinus rhythm and left ventricular hypertrophy (LVH) with strain pattern. A 24-h Holter came back with normal sinus rhythm, no atrial fibrillation, no heart blocks or arrhythmia. Transthoracic echocardiogram revealed concentric LVH, borderline left ventricular function of 45-50%, mild to moderate aortic regurgitation, bicuspid aortic valve and a coarctation of the aorta with a 70 mm Hg gradient across it. Brain MRI demonstrated lacunar infarcts and no AV-malformations. Both carotid arteries were free of atherosclerosis on Doppler. Coronary CT angiogram not only demonstrated the tight coarctation but also showed a rare anomaly of a PLSVC draining into the left atrium (). Anomalous pulmonary drainage and pulmonary arteriovenous malformation were excluded. The approach to management of this patient was discussed in a heart team meeting. It was decided to proceed percutaneously.\nThe patient was brought to the catheterization laboratory. Coronary angiography showed normal coronaries. He did have a significant coarctation with a pressure gradient of 40 mm Hg. Angiographic confirmation of the PLSVC draining into the left superior pulmonary vein was confirmed. A 40 mm CP stent mounted on a 20 × 45 mm BIB balloon was deployed successfully (), guided by fluoroscopy and overdrive pacing. There was complete abolition of the gradient. At a later date, the patient was brought for PLSVC exclusion therapy. Selective angiography of the PLSVC was performed to delineate vessel course and venous drainage (). Using a marker pigtail measurement of the vessel was obtained. The PLSVC measured 9 mm proximally, 10.5 mm at its mid-point and 8 mm near the entrance to the left upper pulmonary vein. The PLSVC was then temporarily occluded with an 8 mm peripheral balloon to make sure that the patient would tolerate closure of the vessel. There was no significant change in the patient’s hemodynamic measurements, and the decision was made to proceed with transcatheter occlusion of the PLSVC which was achieved using a 12 mm Amplatzer vascular plug II (AGA Medical Corporation, Golden Valley, MN) ().
A 13-year-old male presented to our hospital after sustaining injuries from a motor vehicle accident (MVA). The patient had bee sitting unrestrained in the front passenger seat of a car when he met with the accident. He had been found unconscious inside the car. Upon arrival in the emergency room, he regained consciousness. As part of the trauma protocol, the patient underwent a full-body CT, which revealed moderate subgaleal hematoma, small hemorrhagic brain contusion, multiple lung contusion, and moderate-size pseudoaneurysm in the descending aorta just distal to the left subclavian artery (LSCA) with associated mediastinal hematoma (Figure ).\nThe CT scan also revealed hepatic, right renal, and splenic lacerations without any evidence of active bleeding. Multiple fractures in the ribs, sternum, right femur, and tibia were also observed. The patient was subsequently admitted to the pediatric intensive care unit (ICU). After a combined surgical and cardiac team discussion, and in the view of other stable lesions, the decision was made to proceed with treating the aortic pseudoaneurysm with impending rupture first. Because of the presence of intracerebral haemorrhage and visceral organ lacerations, the patient was deemed at high risk for systemic anticoagulation required for an operative aortic repair. Available percutaneous endograft sizes were deemed too large for his descending aortic diameter, and the associated potential risk of vessel injury from the large sheath required to implant the endograft removed this option from consideration. The decision was made to attempt percutaneous implantation of a balloon-expandable covered stent across the pseudoaneurysm in the cardiac catheterization laboratory. Under general anesthesia, the right femoral artery access was obtained, and an 11 French (Fr) sheath was inserted. A pigtail catheter was advanced to the transverse aorta, and an angiogram was performed (Figure ).\nThe angiogram revealed a diameter of 14 mm at the mid-aortic arch, descending aorta immediately after the pseudoaneurysm, and aorta at the level of the diaphragm. The length of the disrupted aortic segment was 22 mm, and it was 10 mm away from the origin of the LSCA. Based on the angiogram measurements, a 16x38 mm BeGraft aortic stent, which is a balloon-expandable covered stent, was used successfully. This was followed by post-stenting dilation with short non-compliant 17 x 30 mm Z-Med balloon (B. Braun, Melsungen, Germany). There was no residual aneurysmal filling, and comparison pressures demonstrated no significant gradient from ascending to descending aorta (Figure ).\nThe patient was transferred in stable condition to the pediatric ICU for further management. His post-catheterization course was uneventful. Subsequently, he underwent several orthopaedic procedures until he was discharged home in good condition.