1Hazem El Beyrouti,1Christoph Düber, 1Daniel-Sebastian Dohle, 1Michail Shestopal
1Johannes Gutenberg University Hospital, Mainz
Port implantation can be associated with an array of serious vascular complications, typically involving the subclavian artery. We report a case where implantation of a port resulted in an iatrogenic perforation of the aortic arch at the level of the left subclavian artery, which was sealed off using a percutaneous vascular closure device.
Material(s) and Method(s):
A 56-year-old female was scheduled for chemotherapy due to nodal-positive breast cancer for which she underwent implantation of a left-sided port. However, upon first use of the implanted port, significant backflow of arterial blood indicated arterial misplacement of the catheter. Contrast enhanced CT scan confirmed the incorrect position, with the 8.5 F catheter directly penetrating the aortic arch at the level of the left subclavian artery; Additionally, there was a separate left vertebral artery originating directly from the aortic arch. Due to the location of the penetration, endovascular stenting (TEVAR) was not possible without covering the left subclavian. Open surgical repair would have included sternotomy. Therefore, we decided for a minimally invasive approach under surgical standby. First, the port chamber was explanted. Subsequently, the port tube was probed with a stiff guidewire, which tip was shaped to avoid damaging the aortic valve. After removing the tube, a suture-mediated closure device was advanced into the aorta with the tip being placed in the left ventricle (figure 1). Finally, the suture was placed and this procedure was repeated with a second percutaneous vascular closure device. Subsequently, both sutures were tightened with the pusher.
Post-operative control CT scanning confirmed complete closure of the arterial perforation with no signs of any residual leak. One year afterwards, the patient remains in a good general condition and is responding well to chemotherapy.
Minimally invasive closure of an aortic arch penetration may be feasible, even if that includes advancing the closure system into the ascending aorta and the left ventricle. Interdisciplinary management is key; A backup including either TEVAR or open surgical repair is mandatory