Endograft Repair of an Aortic Pseudoaneurysm following Gunshot Wound Injury: Impact of Imaging on Diagnosis and Planning of Intervention

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Abstract
Purpose: To describe the endovascular treatment of a gunshot injury to the visceral aorta and the role of various imaging modalities in the staging and planning of the endograft procedure. Methods and Results: The bullet entered the aorta posteriorly beneath the origin of the superior mesenteric artery and traversed the wall in a tangential manner entering the lumen proximal to the renal arteries. Intravascular ultrasound (IVUS) imaging and spiral computed tomography (CT) identified the injury that the initial angiograms failed to demonstrate. Combined use of IVUS and CT imaging enabled observation of the evolution of a pseudoaneurysm until an interval when endograft exclusion was possible. A stent-graft was customized based on precise IVUS and CT dimensional data and implanted successfully through an arteriotomy in the common femoral artery 3 weeks after the initial injury. Three-month follow-up imaging demonstrated continued exclusion of the pseudoaneurysm, and the patient remains well at 16 months. Conclusions: IVUS and spiral CT scans were instrumental in identifying an arteriographically undetected aortic injury. The combined imaging modalities also helped determine the timing for the endovascular procedure and provided the precise measurements for device fabrication and deployment.

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