Midterm Outcomes of Transcatheter Closure of Anastomotic Leak after Ascending Aortic Surgery

Abstract

Objective

This study aimed to evaluate the safety and durability of transcatheter closure of anastomotic leak (AL) after ascending aortic (AAo) surgery.

Methods

From 2016 to 2021, we performed transcatheter closure for 22 patients aged 56.9 ± 12 years (19 male, 86.4%) who sustained anastomotic leak in the ascending aorta (AAoAL) after AAo surgery. Access and device were selected according to the presence of a patent Cabrol (perigraft-to-right atrium [RA]) shunt (n = 16, 72.7%) and leak size.

Results

Fifteen patients had tricuspid regurgitation (TR; 68.2%), 13 were symptomatic (59.1%), and 11 were in the New York Heart Association (NYHA) functional class III/IV (50%). Mean AAoAL diameter was 3.3 ± 1.5 mm. Mean procedural time was 141 ± 53 minutes. Procedural success rate was 86.4% (19/22, 14 with Cabrol shunt). AAoAL was directly closed or coiled in 12 patients. Follow-up was complete in 100% at a mean duration of 4.9 ± 1.1 years (range 3.6–8.1). All patients were alive, and two underwent reoperation. Freedom from death and reoperation was 94.7% at 2 years and 89.5% through 8 years. AAoAL was obliterated in 11, while a trace residual shunt was seen in 8 patients. The aorta at the leak shrank significantly in all (49.1–41.4 mm, p = 0.010). Patients with Cabrol shunt showed a significant shrinkage of the RA (46.9 ± 8.8 mm vs. 39.1 ± 8.2 mm, p = 0.030) and right ventricle (41.4 ± 4.7 mm vs. 30.4 ± 6.2 mm, p < 0.001), along with improved heart function (NHYA class III 4/12, IV 5/12 vs. class III 4/12, IV 0/12, p = 0.032) and alleviation of TR (moderate 6/14, severe 3/14 vs. moderate 2/14, severe 1/14, p = 0.081).

Conclusion

Transcatheter closure may be a feasible, safe, and effective approach to anastomotic leak after ascending aortic surgery in selected patients, which can achieve favorable short- to midterm outcomes.

Keywords

ascending aorta/surgery - anastomotic leak - transcatheter closure

Publication History

Received: 26 January 2025

Accepted: 23 June 2025

Accepted Manuscript online:
24 June 2025

Article published online:
17 July 2025

• References

• 1 Ghazy T, Mahlmann A, Fajfrova Z. et al. Anastomotic leak after surgical repair of type A aortic dissection - prevalence and consequences in midterm follow-up. Vasa 2017; 46 (05) 377-382
• 2 Ma WG, Chen Y, Zhang W. et al. Extended repair for acute type A aortic dissection: long-term outcomes of the frozen elephant trunk technique beyond 10 years. J Cardiovasc Surg (Torino) 2020; 61 (03) 292-300
• 3 Malvindi PG, van Putte BP, Sonker U, Heijmen RH, Schepens MA, Morshuis WJ. Reoperation after acute type A aortic dissection repair: a series of 104 patients. Ann Thorac Surg 2013; 95 (03) 922-927
• 4 Kobuch R, Hilker M, Rupprecht L. et al. Late reoperations after repaired acute type A aortic dissection. J Thorac Cardiovasc Surg 2012; 144 (02) 300-307
• 5 Dougenis D, Daily BB, Kouchoukos NT. Reoperations on the aortic root and ascending aorta. Ann Thorac Surg 1997; 64 (04) 986-992
• 6 Becker D, Stana J, Prendes CF. et al. Endovascular arch repair of anastomotic aneurysm and pseudoaneurysm in patients after open repair of the ascending aorta and aortic arch: a case series. Eur J Cardiothorac Surg 2023; 64 (04) ezad345
• 7 Hegeman RRMJJ, Swaans MJ, Kara B. et al. Transcatheter closure of postsurgical aortic pseudoaneurysms guided by three-dimensional image reconstruction: A single-centre experience. Neth Heart J 2023; 31 (10) 383-389
• 8 Xue YG, Ma WG, Wu WH. et al. Endovascular repair for thoracic aortic false aneurysms: Single-center experience in 102 patients. Ann Thorac Surg 2016; 101 (04) 1410-1417
• 9 Bashir F, Quaife R, Carroll JD. Percutaneous closure of ascending aortic pseudoaneurysm using Amplatzer septal occluder device: The first clinical case report and literature review. Catheter Cardiovasc Interv 2005; 65 (04) 547-551
• 10 Bhindi R, Newton J, Wilson N, Ormerod OJ. Percutaneous plugging of an ascending aortic pseudoaneurysm. JACC Cardiovasc Interv 2008; 1 (03) 327-328
• 11 Cawley PJ, Gill E, Goldberg S. Successful percutaneous closure of an aortic graft pseudo-aneurysm with a patent foramen ovale occluder device. J Invasive Cardiol 2008; 20 (01) E19-E22
• 12 Stasek J, Polansky P, Bis J. et al. The percutaneous closure of a large pseudoaneurysm of the ascending aorta with an atrial septal defect Amplatzer occluder: Two-year follow-up. Can J Cardiol 2008; 24 (12) e99-e101
• 13 Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-case series of six patients. Catheter Cardiovasc Interv 2009; 73 (04) 521-529
• 14 Kannan BR, Jain AK, Qureshi SA, Rothman MT, Rosenthal E, Mathur A. Successful exclusion of large post-surgical pseudoaneurysms of the ascending aorta by a percutaneous approach. Ann Thorac Surg 2009; 87 (04) 1281-1284
• 15 Hussain J, Strumpf R, Ghandforoush A, Wheatley G, Sutherland J. Transcatheter closure of recurrent aortic pseudoaneurysm previously treated by Amplatzer occluder device. J Vasc Surg 2010; 52 (01) 196-198
• 16 Gray BH, Langan III EM, Manos G, Bair L, Lysak SZ. Technical strategy for the endovascular management of ascending aortic pseudoaneurysm. Ann Vasc Surg 2012; 26 (05) 734-738
• 17 Kumar PV, Alli O, Bjarnason H, Hagler DJ, Sundt TM, Rihal CS. Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms. Catheter Cardiovasc Interv 2012; 80 (04) 687-699
• 18 Gendi SM, Kenny D, Hibbeln J, Hijazi ZM. Closure of ascending aorta pseudoaneurysm to right atrium fistula. JACC Cardiovasc Interv 2013; 6 (04) 418-419
• 19 De Boo DW, Mott N, Kavnoudias H, Walton A, Lyon SM. Endovascular closure of ascending aortic pseudoaneurysm with a type II Amplatzer vascular plug. Vasc Endovascular Surg 2014; 48 (04) 329-332
• 20 Jain V, Gruberg L, Bilfinger TV, Tassiopoulos AK, Loh SA. Coil embolization of an aortic pseudoaneurysm after open repair of type A aortic dissection. Ann Vasc Surg 2014; 28 (05) 1312.e1-1312.e5
• 21 Patel AV, Gupta S, Laffin LJ, Retzer EM, Dill KE, Shah AP. One size does not fit all: Case report of two percutaneous closures of aortic pseudoaneurysm and review of the literature. Cardiovasc Revasc Med 2014; 15 (03) 160-164
• 22 Lyen SM, Rodrigues JC, Manghat NE, Hamilton MC, Turner M. Endovascular closure of thoracic aortic pseudoaneurysms: A combined device occlusion and coil embolization technique in patients unsuitable for surgery or stenting. Catheter Cardiovasc Interv 2016; 88 (07) 1155-1169
• 23 Quevedo HC, Alonso A. Endovascular therapy for ascending aorta pseudoaneurysm. Cardiovasc Revasc Med 2016; 17 (08) 586-588
• 24 Russo MJ, M R, Shah AP. Percutaneous transcatheter closure of a large pseudoaneurysm arising from anastomosis of a surgical graft with an Amplatzer vascular plug 4. Vasc Dis Manage 2016; 13: E53-E57
• 25 Steinberg ZL, Don CW, Sun JC, Gill Jr EA, Goldberg SL. Percutaneous repair of aortic pseudoaneurysms: A case series. J Invasive Cardiol 2016; 28 (01) E6-E10
• 26 Pu J, Ke Y, Huang L, Wu W. Transcatheter closure of aortic anastomosis leak resulting in patent Cabrol shunt after aortic replacement. JACC Cardiovasc Interv 2017; 10 (20) 2126-2128
• 27 Tang L, Lesser JR, Gössl M. et al. Transcatheter closure of complex ascending aortic pseudoaneurysms after cardiac surgery. Circ Cardiovasc Interv 2018; 11 (09) e007052
• 28 Yalçın AA, Kahraman S, Yıldırım A, Erkanlı K. An uncommon percutaneous treatment of aortic pseudoaneurysm. Anatol J Cardiol 2018; 20 (02) 132-133
• 29 Kanda BS, Hoyt NE, Haas J. et al. Percutaneous percutaneous repair of an aortic pseudoaneurysm status post-surgical repair of Stanford type A dissection. Int J Clin Cardiol 2020; 7: 166
• 30 Wu W, Ke Y, Zhao H, Huang L, Pu J. Trans-catheter closure of aortic anastomosis leak after aortic replacement: Classifications and techniques. J Thorac Dis 2020; 12 (09) 4883-4891
• 31 Matsuzawa T, Kasai M, Yamabe K. et al. Successful endovascular treatment of an ascending aortic pseudoaneurysm using an Amplatzer Vascular Plug II. Gen Thorac Cardiovasc Surg 2021; 69 (01) 91-93
• 32 Stehli J, Alie-Cusson FS, Panneton JM, Mahoney PD. Percutaneous closure of iatrogenic ascending aortic pseudoaneurysms following surgical aortic repair. JACC Case Rep 2021; 3 (02) 327-333
• 33 Santoro G, Rizza A, Pizzuto A. et al. Transcatheter treatment of ascending aorta pseudoaneurysm guided by 3D-model technology. JACC Case Rep 2022; 4 (06) 343-347
• 34 Lin HC, Lee YT, Yin WH, Wei J. A case report of transcatheter closure of post-Bentall ascending aortic pseudoaneurysm due to coronary button dehiscence. Eur Heart J Case Rep 2023; 7 (11) ytad516
• 35 Ma WG, Zhu JM, Zheng J. et al. Sun's procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg 2013; 2 (05) 642-648
• 36 Lock JE, Block PC, McKay RG, Baim DS, Keane JF. Transcatheter closure of ventricular septal defects. Circulation 1988; 78 (02) 361-368