The Use of Three-Dimensional (3D) Printing for the Surgical Management of Pseudoaneurysm after Stent Implantation

Objectives: Three-dimensional (3D) printing is an established tool for preprocedural planning in complex congenital heart disease. The concept of 3D printing consists of converting a medical image data set into a three-dimensional model, combining haptic and visual information. Pseudoaneurysm formation is a rare complication after thoracic endovascular stent implantation. The role of 3D printing in the surgical management of complex pseudoaneurysm cases is not sufficiently evaluated. Therefore, we present a case of surgical management of a pseudoaneurysm of the right-sided aortic arch after stent implantation for coarctation in a 36-year-old woman with a previous history of ventricle septal defect closure in early childhood.

Methods: We developed a 3D printing model of the thorax including the heart, the aorta and supra aortic vessels (including the pseudoaneurysm) based on CT angiography data. Images were exported as standard DICOM data. Regions of interest segmentation and surface reconstruction were performed using 3D Slicer software (Version 4.10.2). The model was used for detailed preprocedural planning including cannulation strategy. With the help of the model the patient was introduced to her pathology and the upcoming procedure.

Results: Surgery was performed via median sternotomy. Cardiopulmonary bypass was established through cannulation of the aorta ascendens (beating heart) and femoral vessel. The pseudoaneurysm was carefully exposed and resected. The aortic arch and proximal descending aorta were replaced with an 18-mm tubular prosthesis. Surgery was uneventful and the patient was discharged after 10 days. Short-term follow-up of the patient revealed no new symptoms or neurological deficits.

Conclusion: The use of 3D printing for the surgical treatment of complex aortic pseudoaneurysm cases is not sufficiently evaluated. Although CTA provides all necessary information, the plasticity of a 3D model visualizes the complexity of the pathology and relations of the anatomical structures and therefore facilitates the approach and intraoperative management. In this case, surgical strategy was tailored according to the preoperatively generated 3D model. Median sternotomy instead of lateral thoracotomy was chosen as it provides a better overview during pseudoaneurysm resection with protection of nerve structures and great vessels. As there is no standard surgical approach in these rare conditions, 3D printing can be an essential addition towards patient tailored surgery and better patient education.