Coil Embolization for a New Ulcer-Like Projection Near the Distal Anastomosis After a Hemiaortic Arch Replacement

Ulcer-like projections (ULPs) with a tendency to enlarge are at risk of aortic events such as new dissection, aneurysmal formation, or rupture and require therapeutic intervention. However, what should be done after open chest surgery when standard thoracic endovascular aortic repair (TEVAR) cannot be performed is debatable. Here, we present a case of coil embolization of a newly enlarged ULP that was not amenable to TEVAR following a hemiarch aortic arch repair. A 68-year-old male with a history of ascending and hemiaortic arch repair for acute type A aortic dissection presented with a chief complaint of chest pain three months prior to presentation. A post-type A dissection ULP remained in the aortic arch but had enlarged over the three months. Therapeutic intervention was planned to avoid aortic events; however, standard and fenestrated TEVAR were going to be anatomically challenging. Since the patient was in poor general condition after diverticulitis and stroke, reopened total arch replacement and total debranching TEVAR were avoided. The neck of the ULP was narrow and had a small volume; therefore, we assessed that the coil-packing method could embolize the ULP. Coil embolization was successful, and the patient had no postoperative complications. A computed tomography scan at the remote stage showed no recanalization or enlargement, and the patient was stable. Coil embolization may be attempted for arch ULP that can enlarge if the ULP can be embolized with intra-aneurysmal packing when it is difficult to perform a reopen surgery or TEVAR, including standard zone II, total debranching, and fenestrated TEVAR.