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Treatment of a sternotomy-related false aneurysm using a covered stent-graft

Department of Imaging Hammersmith Hospital Du Cane Road London W12 0NN UK

The Editor—Sir,

We read with interest the recent case report by Callaway et al [1] in which the authors describe the treatment of a sternotomy-related false aneurysm involving a branch vessel of the left internal mammary artery by placing a covered stent across its origin. They successfully induced thrombosis of the false aneurysm lumen after some 2 months. We suggest that this was due more to good fortune than good technique.

Blocking the origin of a vessel feeding to a false aneurysm, in this case a branch vessel of the left internal mammary artery, is not a sound embolisation strategy as it fails to recognize the anastomotic or collateral pathways that are present or that may rapidly develop and continue to fill the aneurysmal cavity after this has been performed. Furthermore, this technique is likely to prevent, or make considerably more difficult, definitive treatment by embolisation in the likely event that the false aneurysm remains patent.

The arteriogram after stent deployment and thrombolysis shown in Figure 3 demonstrates that the origin of the artery from which the pseudoaneurysm arose has been occluded. Persisting flow within the aneurysmal sac for 2 months following treatment was, therefore, not due to "porosity of the stent", as the authors suggest, but due to its continued perfusion via collaterals. Although the authors have named this branch an anterior intercostal artery, it is more likely to be a perforating branch of the internal mammary artery, given its proximity to a sternotomy wire and the very superficial location of the pseudoaneurysm on clinical examination [2]. Potential collateral routes to this vessel after its proximal occlusion include pectoral branches of the anterior intercostal, acromiothoracic and lateral thoracic arteries. It is these that will have continued to supply the pseudoaneurysm in this case.

The two definitive methods of treatment of this pseudoaneurysm would have been either percutaneous thrombin injection, as the authors discuss, or transcatheter embolisation. The latter technique would have required the selective catheterization of the perforating artery with a coaxial catheter to a point immediately beyond the pseudoaneurysm origin. Coils would then be placed at this site prior to more proximal occlusion being performed so as to close both the "front" and "back doors"—an important basic principle of embolisation. It is likely that this method of treatment would have been possible in this case on the basis of the image submitted.

Yours etc.,

Received for publication January 30, 2001. Accepted for publication February 16, 2001.

References

1. Callaway MP, Wilde P, Angelini G. Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture. Br J Radiol 2000;73:1317–9.[Abstract]
2. Netter FH. Atlas of human anatomy. New Jersey, NY: Ciba-Geigy Corporation, 1996.

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