Case Report

1Servicio dHospital Virge

2Clinic forZurich, Switze

3Institute oHospital Zuric

Correspondschirurgie, UnSwitzerland; E

Ann Vasc Surghttp://dx.doi.or� 2014 Elsevi

Manuscript rec

31, 2013; pub

A Hybrid Open and Endovascular Repair forTreatment of Bovine Aortic Arch AneurysmAccompanied by Aneurysm of Patent DuctusArteriosus with Deployment of AmplatzerDuct Occluder

Jose Gil-Sales,1 Mario Lachat,2 Zoran Rancic,2 Dieter Mayer,2 Thomas Pfammatter,3

and Lyubov Chaykovska,2 Toledo, Spain and Zurich, Switzerland

A rare case of bovine aortic arch aneurysm accompanied by patent ductus Botalli aneurysm wastreated using an off-pump hybrid procedure including supraaortic debranching combined withaortic stent grafting and oversewing of pulmonary artery end of the aneurysm. Postoperativecomputed tomography angiography showed persistent perfusion of the ductus Botalli aneurysmfrom pulmonary artery, which was successfully closed with an Amplatzer duct occluder. Twenty-two months of follow-up showed good general state of the patient’s health status. This less inva-sive procedure is an alternative to aortic replacement under circulatory arrest and may be theonly salvage option for patients in poor general condition.

Ductus arteriosus (DA) or ductus Botalli is a

vascular structure that connects the proximal

descending aorta to the roof of the main pulmonary

artery.1 This is an essential structure for normal

fetal development. After birth, medial smoothmus-

cle fibers in DA contract, which results in lumen

obliteration and formation of ligamentum arterio-

sum. Persistent DA is a rare disorder, which is

mainly diagnosed in childhood. Ductus arteriosus

aneurysm (DAA) is an entity evenmore infrequent.

Most cases are diagnosed in children2,3 and rarely in

adults.4,5

e Cirugı́a Vascular, Complejo Hospitalario de Toledo,n de la Salud, Toledo, Spain.

Cardiovascular Surgery, Zurich University Hospital,rland.

f Diagnostic and Interventional Radiology, Universityh, Zurich, Switzerland.

ence to: Lyubov Chaykovska, Klinik f€ur Herz- und Gef€as-iversit€atsSpital Z€urich, R€amistrasse 100, Zurich 8091,-mail: lyubov.chaykovska@usz.ch

2014; -: 1–4g/10.1016/j.avsg.2013.12.016er Inc. All rights reserved.

eived: August 23, 2013; manuscript accepted: December

lished online: ---.

We report a case of a 79-year-old man with a

large symptomatic DAA combined with an aortic

arch aneurysm and bovine arch.

CASE REPORT

History of the Disease and Patient

Characteristics

A 79-year-old man in poor general condition was referred

to us from the peripheral hospital, where hewas presented

with approximately 3 weeks history of neck pain, hoarse-

ness, dysphagia, nausea, fatigue, fever, and increased C-

reactive protein (73 mg/L). His past medical history was

significant for hypertension. Hemodynamic status of the

patient was stable with a blood pressure of 160/

100 mmHg. Moderate respiratory failure with sufficient

blood oxygen saturation while receiving 5 L of oxygen

perminute via a simple facemaskwas presented. The path-

ologic findings of the thoracic aorta in a thoracoabdominal

computed tomography angiography (angioCT)were inter-

preted in the referral hospital as a pseudoaneurysm of the

aortic arch. At that point, the patient was referred to us.

Diagnostic Tests

Upon admission to our hospital, reevaluation of the angio

CT was performed and a bovine aortic arch aneurysm

1

2 Case Report Annals of Vascular Surgery

(4.0� 3.2 cm) accompanied by large (8� 9.5 cm) partially

thrombosed aneurysm of the patent ductus Botalli with

compression of the esophagus, left main bronchus, left

pulmonary artery, acute pulmonary embolism, and a

bovine arch was diagnosed (Fig. 1). In addition, moderate

right-sided pleural effusion and a small left-sided one

were diagnosed. Echocardiography was performed imme-

diately after admission. It showed normal unchanged left

ventricle with normal ejection fraction (65%) and dia-

stolic function. Mild tricuspid insufficiency with un-

changed right cardiac chambers was accompanied by

severe pulmonary hypertension (mean pulmonary artery

pressure was 51 mmHg and pulmonary artery systolic

pressure was 53 mmHg).

First Procedure

After hospitalization, the patient was intubated and deliv-

ered into the operation room for the aneurysm repair. The

aorta was approached by a median sternotomy. No car-

diopulmonary bypass was performed. At first, bypass be-

tween left subclavian artery and left common carotid

artery (LCCA) with 8-mm graft was performed using a

Viabahn Open Revascularization Technique.6 A hand-

made Y-graft (8-mm end-to-side graft connected to a

13-mm graft) was made for debranching of brachioce-

phalic trunk (BCT) and LCCA. A 13-mm tube of this Y-

graft was connected proximally end-to-side to the

ascending aorta and distally end-to-side to the BCT. An

8-mm part of the Y-graft was connected end-to-side to

the LCCA. All native supraaortic vessels were tied proxi-

mally to the anastomosis site. Then, self-expandable

thoracic endoprothesis� (W.L. Gore and Associates, Inc.,

AZ) was placed into the thoracic aorta (zone 0 to zone

4). A completion arteriogram showed an excellent aortic

position of the endograft, exclusion of the ductus Botalli

aneurysm from the aortic side, and patency of the supra-

aortic grafts with persistent communication between

ductus Botalli aneurysm and pulmonary artery. There-

fore, the pulmonary artery end of the aneurysm was

oversewn.

Early Postoperative Outcomes and

Examinations after the First Step of the

Multisteps Procedure

The patient tolerated the procedure well, but the postop-

erative course was complicated by prolonged (7 days)

ventilatory support secondary to patient’s pulmonary

embolism. After 16 days of the intensive care unit stay,

he was transferred to the ordinary ward. Postoperative

angio CT on the first postoperative day revealed a type II

endoleak from the persistent communication between

ductus Botalli and pulmonary artery with unchanged

size of the aneurysm sac. Angio CT was repeated on day

20 postsurgery and it showed that the communication be-

tween ductus Botalli and pulmonary artery was still pre-

sent and the size of the aneurysm sac had slightly

increased (8.6 � 9.5 cm).

Second Procedure

To correct type II endoleak from the persistent communi-

cation between ductus Botalli and pulmonary artery,

endovascular closure of the ductus Botalli from the pul-

monary artery was performed successfully on the day 24

after the first procedure. For this purpose, an Amplatzer

9-PDA-009 duct occluder was placed under local anes-

thesia via the right femoral vein. Periprocedural angiog-

raphy showed complete exclusion of ductus Botalli

aneurysm from the stented aorta (Fig. 2A) and the pulmo-

nary trunk (Fig. 2B).

Outcomes and Follow-up

The further postoperative course was uneventful.

Dysphagia and hoarseness noticed preoperatively per-

sisted in the early postoperative period andwere improved

during the first 3 weeks after the first procedure. The pa-

tient was discharged on the 26th day after admission

and the first operation. Angio CT 2 days after Amplatzer

duct occluder implantation showed a complete exclusion

and a slight reduction of the aneurysm sac (7.6 � 8.1 cm

compared with 8 � 9.5 cm before surgery; Fig. 3). The pa-

tient was followed-up for 22 months after surgery and his

general health status was good.

DISCUSSION

This is the first report on hybrid repair of a symp-

tomatic aortic arch aneurysm accompanied by pat-

ent ductus Botalli aneurysm and bovine aortic

arch aneurysm. We first report on supraaortic

debranching technique completed by Thoracic

endovascular aortic repair (TEVAR) for closure of

an aortic orifice and Amplatzer duct occluder for

closure of the persistent type II endoleak from pul-

monary artery.

This is a second case of a successful hybrid open

and endovascular repair of the thoracic aorta aneu-

rysm associated with ductus Botalli aneurysm.

Reports on ductus Botalli aneurysm treatment

are few in the literature and reports on concomitant

aortic arch aneurysms are even more rarer.7,8 In the

preendovascular era, this pathology was treated

with an open approach through a left posterolateral

thoracotomy using cardiopulmonary bypass. In the

review of Saito et al.,9 39 cases of open surgery for

the treatment of ductus Botalli aneurysms were

described through 2004.

Open surgical repair of the DA is an extensive

procedure with high perioperative risks.10 Open

aneurysm repair with cardiopulmonary bypass was

associated with perioperative mortality rates of up

to 16.5% and stroke rates about 18%11 (for the

review).

Fig. 2. Perioperative angiography of the pulmonary trunk showing complete exclusion of ductus Botalli aneurysm

from the (A) stented aorta and (B) pulmonary trunk.

Fig. 3. Postoperative computed tomography angiog-

raphy. (A, B) Three-dimensional reconstructions

showing complete exclusion of the ductus Botalli, patent

supraaortic trunks, and the endovascular graft in the

thoracic aorta. (C) Axial view showing complete throm-

bosis of the residual ductus Botalli aneurysm and an

Amplatzer occluder.

Fig. 1. Preoperative computed tomography angiography. (A) Three-dimensional reconstruction showing ductus

Botalli aneurysm. (B) Ductus Botalli aneurysm in axial view.

Vol. -, No. -, - 2014 Case Report 3

Endovascular methods of aneurysm repair alone

or in combination with mininvasive open surgery

become a treatment of choice and is sometimes the

only treatment option in high-risk polymorbid pa-

tients, as it was in our case.

Despite obvious benefits of endovascular treat-

ment, this method is still underused in the treat-

ment of ductus Botalli aneurysms. Between 2004

and 2012, 14 cases of DA aneurysm repair were

reported and reviewed by Psathas et al.11 Only 6

procedures out of 14 were performed using a less

invasive endovascular technique. In the up to date

literature, 3 cases of hybrid repair with supraaortic

debranching and TEVAR were published7,8,11; one

of them was successfully performed in our clinic.8

In the case presented here, we first faced the prob-

lem of endoleak via pulmonary artery, which was

successfully repaired with an Amplatzer occlusion.

4 Case Report Annals of Vascular Surgery

Placement of the Amplatzer occluder is a treatment

of choice for closure of a ductus Botalli.1 It has pre-

viously been successfully used also for closure of

asymptomatic ductus Botalli aneurysms.12,13

CONCLUSION

This is the second case report from our clinic,

showing a successful hybrid open debranching and

endovascular repair of a concomitant bovine arch

and a symptomatic patent ductus Botalli aneurysm.

Amplatzer duct occluder is a good tool for closure of

a persistent fistula between the ductus Botalli aneu-

rysm and the pulmonary artery.

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