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Objective: The rate of acute complications after pacemaker implantation is 4 - 5%.Here in we report treatment with thoracic stent-graft implantation (TEVAR) of a rarely described dramatic complication: an aortic injury due to direct puncture of the
distal aortic arch with malplacement of the two pacing leads in the left ventricle and in the left circumflex artery. After pacemaker implantation a 74-year-old woman showed a progressive decrease in haematocrit with elevation of cardiac troponin-I. Coronary angiography revealed the malposition of the catheters introduced through the aortic wall. The atrial lead was placed in the left circumflex coronary artery. Computed tomography scan confirmed distal aortic arch perforation (Fig. 1). We considered it necessary and urgent to remove the malpositioned leads, and treat the aortic injury. We opted for endovascular treatment with thoracic stent-graft placement because of the evolving haemothorax and myocardial ischaemia.
Methods: Stentgraft placement was performed in a hybrid operating room under general anaesthesia. Through left femoral artery access a Medtronic Valiant stent-graft was implanted in the distal aortic arch covering the left subclavian artery( LSA) origin, while the two catheters were removed from the pocket of subclavian access. At the same time a new VVI pacemaker was implanted through a right subclavian access. Subsequent aortography confirmed the adequacy of the treatment and the absence of bleeding from the aortic wall, while the coronary angiography showed the dissection with a subocclusion of the LCX artery.
We decided not to treat the coronary at the same time in order to reduce the risk of bleeding. Three days later, the patient underwent percutaneous coronary intervention (PCI) on the dissected left circumflex artery. Four days later the patient was discharged.
Results: At five-year follow-up the patient was in good condition, showing no signs of steal phenomena due to the intentional occlusion of the LSA. The CT scan confirmed successful repair of the injured aorta.
Conclusions: Endovascular stent grafting has emerged as a less invasive therapeutic alternative to treat traumatic or iatrogenic injuries of the distal aortic arch.