TEVAR for ruptured mycotic aneurysm in a patient with a left ventricular assist device

To report endovascular treatment of a ruptured mycotic aneurysm in a patient with previous cardiac surgery, a cardioverter-defibrillator, and an intrathoracic left ventricular assist device (LVAD).

A 75-year-old man was admitted for a syncopal episode and severe back pain. The patient had a past history of postischemic dilatative cardiomyopathy for which a cardioverter-defibrillator was implanted. An LVAD and bioprosthetic aortic valve were subsequently placed due to severe cardiogenic shock. The postoperative course was complicated by methicillin-resistant Staphylococcus aureus mediastinitis and acute renal failure requiring temporary dialysis. At the current admission 4 months later, urgent computed tomography (CT) showed a ruptured aneurysm in the middle third of the descending thoracic aorta; blood cultures were positive for Candida sp . The patient was hemodynamically stable, so he was placed in intensive care and given targeted antimicrobial therapy while an endovascular treatment was planned. At surgery, a rifampicin-soaked Relay Plus 30-mm×95-cm stent-graft was deployed through a right common femoral cutdown to seal the aortic rupture. Successful aneurysm exclusion was confirmed by intraoperative transesophageal echocardiography (TEE). At the 6-month follow-up, the patient was without recurrent pathology or graft infection as demonstrated by CT.

Thoracic endovascular aortic repair in patients with LVAD is peculiar for several aspects: accurate planning is necessary to adequately visualize the aortic lesion despite the presence of many radiopaque devices and the femoral arteries are pulseless. Moreover, extremely slow washout of contrast from the aortic rupture prevents correct assessment of final sac exclusion with angiography; intraoperative TEE monitoring proved extremely useful.