Emergent Endovascular Repair of a Ruptured Ascending Aorta Pseudoaneurysm With Thoracic Aortic Stent Graft.

Pseudoaneurysm of the ascending aorta is a rare complication of cardiac surgery due to tissue degeneration at the site of graft anastomosis, aortotomy, or extracorporeal circulation cannulation. We describe the case of a patient who developed an ascending aorta pseudoaneurysm after coronary artery bypass graft surgery, which initially required percutaneous closure with an atrial septal defect occlusion device. However, three years later the patient presented again with active external bleeding secondary to pseudoaneurysm enlargement and rupture, which was emergently repaired by percutaneous endovascular repair with a thoracic aortic stent graft. At one-year follow-up the patient is in good conditions and asymptomatic.

Global Chronic Total Occlusion Crossing Algorithm: JACC State-of-the-Art Review.

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.