Case Study
Enlarged coronary artery pseudoaneurysm after drug-eluting stent implantation
Asian Cardiovascular & Thoracic Annals 21(5) 608–611 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312461454 aan.sagepub.com
Daijiro Hori, Kenichiro Noguchi, Yohei Nomura and Hiroyuki Tanaka
Abstract A 73-year-old man with 2-vessel coronary artery disease underwent a staged percutaneous coronary intervention that resulted in rupture of the right coronary artery and pseudoaneurysm formation. Although the pseudoaneurysm regressed over a week, it reexpanded after a year. Resection of the pseudoaneurysm and coronary artery bypass grafting were performed. The drug-eluting stent at the coronary artery injury site may have delayed healing and remodeling of the artery, thus contributing to reexpansion of the pseudoaneurysm.
Keywords Aneurysm, false, angioplasty, balloon, coronary, coronary aneurysm, drug-eluting stents, paclitaxel
Introduction Coronary artery aneurysm formation has been reported to occur in 4% of patients who undergo percutaneous balloon angioplasty.1 However, today, in the drug-eluting stent era, reports of coronary artery aneurysm after drug-eluting stent implantation are rare.2 We describe a case of coronary artery pseudoaneurysm caused by excessive percutaneous balloon angioplasty. The pseudoaneurysm re-enlarged after a slight regression in size. The presence of a drug-eluting stent in the pseudoaneurysm may have contributed to the reexpansion of the pseudoaneurysm.
Case report A 73-year-old man with a history of cerebral infarction was admitted for treatment of 2-vessel coronary artery disease (Figure 1(a) and (b)). A staged percutaneous coronary intervention of the left anterior descending and right coronary arteries was scheduled. Treatment of the left anterior descending artery was performed with an Endeavor stent (Medtronic, Minneapolis, MN, US), and treatment of the right coronary artery
followed after 1 month. A Taxus stent (Boston Scientific, Natick, MA, US) and a Promus stent (Boston Scientific, Natick, MA, US) were deployed in the 90% stenosed right coronary artery. However, balloon angioplasty after Taxus stent implantation resulted in over extension of the coronary artery, leading to perforation of the coronary vessel (Figure 1(c)). Long inflation of the balloon at the injury site was successful in controlling extravasation, and the hematoma was contained (Figure 1(d)). Coronary angiography was performed the next day, which showed that the extravasation had resolved and blood flow to the distal right coronary artery was preserved (Figure 2(a)). Coronary computed tomography angiography performed a week after the procedure revealed regression of the hematoma, and the patient was discharged from Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Kanagawa, Japan Corresponding author: Daijiro Hori, MD, Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, 1-30 Fujikaoka, Aoba, Yokohama city, Kanagawa 227-8501, Japan. Email: [email protected]
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Figure 1. (a), (b) Coronary artery angiogram revealing 2-vessel coronary disease. (c) Percutaneous coronary intervention in the right coronary artery resulted in coronary artery injury. (d) Long balloon inflation was successful in controlling the hematoma.
the hospital on postoperative day 14 (Figure 2(b)). The hematoma was slightly increased in size on a coronary computed tomography angiogram and on a coronary artery angiogram 3 months after the procedure (Figure 2(c) and (d)). Coronary angiography was repeated 10 months after the intervention and it showed an enlarging pseudoaneurysm (Figure 2(e) and (f)). Surgical treatment was undertaken. The right epiploic gastric artery was dissected, and offpump coronary artery bypassing was carried out on the right coronary artery distal to the pseudoaneurysm. The pseudoaneurysm was dissected, and the afferent/efferent arteries were closed with a mattress suture. The pseudoaneurysm was opened, and the position of the Taxus stent was confirmed. The stent was observed throughout the aneurysm, and the possibility of stent edge injury was excluded. Because the stent could not be removed due to adhesions, the pseudoaneurysm was closed directly with a mattress suture (Figure 3). The postoperative course was uneventful, and coronary computed tomography angiography showed extirpation of the
aneurysm and distal perfusion of the right coronary artery via the right epiploic gastric artery.
Discussion Coronary artery pseudoaneurysms after percutaneous interventions have been reported to occur after perforation of the vessel wall, and are associated with an adverse outcome if untreated. The risks associated with pseudoaneurysm include thrombosis with distal embolization as well as rapid enlargement leading to rupture and cardiac tamponade. There is no standard therapy for pseudoaneurysm and it should be decided for each case encountered.3 Coronary artery aneurysms after percutaneous interventions have been observed from 1 week to 4 years after drug-eluting stent implantation.4 Different factors have been suggested as possible reasons for aneurysm formation after intervention, including drug toxicity, an inflammatory response, infection, and acute vessel damage during the initial procedure.4–6 Hassan and colleagues7 reported that the risk of late stent malposition
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
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Asian Cardiovascular & Thoracic Annals 21(5)
Figure 2. (a) Coronary artery angiogram 1 day after the procedure showing disappearance of the extravasation. (b) Computed tomography 1 week after the procedure showing regression of the hematoma. (c), (d) The hematoma was slightly enlarged on computed tomography and coronary artery angiography 3 months after the procedure. (e), (f) Computed tomography and coronary artery angiography 10 months after the procedure revealed enlargement of the pseudoaneurysm.
in patients with drug-eluting stents was 4-times higher than that in patients with bare metal stents, suggesting that the complication is associated with drug-eluting stents. Paclitaxel, which is used in the Taxus stent, is an antineoplastic drug from the taxane class, which inhibits cell replication.8 Local inflammatory responses to these drugs may delay the healing process, thus causing aggravated pseudoaneurysm formation after perforation of the coronary vessels. Because we did not perform an intravascular ultrasound examination we
cannot be absolutely sure that this was a pseudoaneurysm. However, the coronary vessel perforation at the initial intervention suggests pseudoaneurysm. The presence of a drug-eluting stent may have contributed to a delay in the healing process, thus resulting in formation of the re-enlarging coronary pseudoaneurysm. Coronary artery injury associated with drug-eluting stents should be carefully observed for possible delays in the healing process, potentially leading to an enlarging pseudoaneurysm.
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
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Figure 3. (a) Intraoperative image showing the right coronary artery pseudoaneurysm. (b) The pseudoaneurysm was opened, revealing the implanted drug-eluting stent. (c) The pseudoaneurysm was closed with a mattress suture, and bypass surgery involving the right epiploic gastric artery was performed.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Bal ET, Thijs Plokker HW, van den Berg EM, Ernst SM, Gijs Mast E, Gin RM, et al. Predictability and prognosis of PTCA-induced coronary artery aneurysms. Cathet Cardiovasc Diagn 1991; 22: 85–88. 2. Ovu¨nc¸ K, Yorgun H and Ozer N. Multiple coronary artery aneurysm formation one year after and four years after sirolimus-eluting coronary stent implantation. Cardiovasc Revasc Med 2009; 10: 252–254. 3. Aqel RA, Zoghbi GJ and Iskandrian A. Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review. Echocardiography 2004; 21: 175–182.
4. Aoki J, Kirtane A, Leon MB and Dangas G. Coronary artery aneurysms after drug-eluting stent implantation [Review]. JACC Cardiovasc Interv 2008; 1: 14–21. 5. Singh H, Singh C, Aggarwal N, Dugal JS, Kumar A and Luthra M. Mycotic aneurysm of left anterior descending artery after sirolimus-eluting stent implantation: a case report. Catheter Cardiovasc Interv 2005; 65: 282–285. 6. Cafri C, Gilutz H, Kobal S, Esanu G, Weinstein JM, AbuFul A, et al. Rapid evolution from coronary artery dissection to pseudoaneurysm after stent implantation: a glimpse at the pathogenesis using intravascular ultrasound. J Invasive Cadiol 2002; 14: 286–289. 7. Hassan AK, Bergheanu SC, Stijnen T, van der Hoeven BL, Snoep JD, Plevier JW, et al. Late stent malapposition risk is higher after drug-eluting stent compared with baremetal stent implantation and associates with late stent thrombosis. Eur Heart J 2010; 31: 1172–1180. 8. Wang D and Gunalingam B. Coronary artery aneurysms associated with a Paclitaxel coated stent. Heart Lung Circ 2008; 17: 66–69.
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
Enlarged coronary artery pseudoaneurysm after drug-eluting stent implantation
Asian Cardiovascular & Thoracic Annals 21(5) 608–611 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312461454 aan.sagepub.com
Daijiro Hori, Kenichiro Noguchi, Yohei Nomura and Hiroyuki Tanaka
Abstract A 73-year-old man with 2-vessel coronary artery disease underwent a staged percutaneous coronary intervention that resulted in rupture of the right coronary artery and pseudoaneurysm formation. Although the pseudoaneurysm regressed over a week, it reexpanded after a year. Resection of the pseudoaneurysm and coronary artery bypass grafting were performed. The drug-eluting stent at the coronary artery injury site may have delayed healing and remodeling of the artery, thus contributing to reexpansion of the pseudoaneurysm.
Keywords Aneurysm, false, angioplasty, balloon, coronary, coronary aneurysm, drug-eluting stents, paclitaxel
Introduction Coronary artery aneurysm formation has been reported to occur in 4% of patients who undergo percutaneous balloon angioplasty.1 However, today, in the drug-eluting stent era, reports of coronary artery aneurysm after drug-eluting stent implantation are rare.2 We describe a case of coronary artery pseudoaneurysm caused by excessive percutaneous balloon angioplasty. The pseudoaneurysm re-enlarged after a slight regression in size. The presence of a drug-eluting stent in the pseudoaneurysm may have contributed to the reexpansion of the pseudoaneurysm.
Case report A 73-year-old man with a history of cerebral infarction was admitted for treatment of 2-vessel coronary artery disease (Figure 1(a) and (b)). A staged percutaneous coronary intervention of the left anterior descending and right coronary arteries was scheduled. Treatment of the left anterior descending artery was performed with an Endeavor stent (Medtronic, Minneapolis, MN, US), and treatment of the right coronary artery
followed after 1 month. A Taxus stent (Boston Scientific, Natick, MA, US) and a Promus stent (Boston Scientific, Natick, MA, US) were deployed in the 90% stenosed right coronary artery. However, balloon angioplasty after Taxus stent implantation resulted in over extension of the coronary artery, leading to perforation of the coronary vessel (Figure 1(c)). Long inflation of the balloon at the injury site was successful in controlling extravasation, and the hematoma was contained (Figure 1(d)). Coronary angiography was performed the next day, which showed that the extravasation had resolved and blood flow to the distal right coronary artery was preserved (Figure 2(a)). Coronary computed tomography angiography performed a week after the procedure revealed regression of the hematoma, and the patient was discharged from Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, Kanagawa, Japan Corresponding author: Daijiro Hori, MD, Department of Cardiovascular Surgery, Fujigaoka Hospital, Showa University, 1-30 Fujikaoka, Aoba, Yokohama city, Kanagawa 227-8501, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
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Figure 1. (a), (b) Coronary artery angiogram revealing 2-vessel coronary disease. (c) Percutaneous coronary intervention in the right coronary artery resulted in coronary artery injury. (d) Long balloon inflation was successful in controlling the hematoma.
the hospital on postoperative day 14 (Figure 2(b)). The hematoma was slightly increased in size on a coronary computed tomography angiogram and on a coronary artery angiogram 3 months after the procedure (Figure 2(c) and (d)). Coronary angiography was repeated 10 months after the intervention and it showed an enlarging pseudoaneurysm (Figure 2(e) and (f)). Surgical treatment was undertaken. The right epiploic gastric artery was dissected, and offpump coronary artery bypassing was carried out on the right coronary artery distal to the pseudoaneurysm. The pseudoaneurysm was dissected, and the afferent/efferent arteries were closed with a mattress suture. The pseudoaneurysm was opened, and the position of the Taxus stent was confirmed. The stent was observed throughout the aneurysm, and the possibility of stent edge injury was excluded. Because the stent could not be removed due to adhesions, the pseudoaneurysm was closed directly with a mattress suture (Figure 3). The postoperative course was uneventful, and coronary computed tomography angiography showed extirpation of the
aneurysm and distal perfusion of the right coronary artery via the right epiploic gastric artery.
Discussion Coronary artery pseudoaneurysms after percutaneous interventions have been reported to occur after perforation of the vessel wall, and are associated with an adverse outcome if untreated. The risks associated with pseudoaneurysm include thrombosis with distal embolization as well as rapid enlargement leading to rupture and cardiac tamponade. There is no standard therapy for pseudoaneurysm and it should be decided for each case encountered.3 Coronary artery aneurysms after percutaneous interventions have been observed from 1 week to 4 years after drug-eluting stent implantation.4 Different factors have been suggested as possible reasons for aneurysm formation after intervention, including drug toxicity, an inflammatory response, infection, and acute vessel damage during the initial procedure.4–6 Hassan and colleagues7 reported that the risk of late stent malposition
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
610
Asian Cardiovascular & Thoracic Annals 21(5)
Figure 2. (a) Coronary artery angiogram 1 day after the procedure showing disappearance of the extravasation. (b) Computed tomography 1 week after the procedure showing regression of the hematoma. (c), (d) The hematoma was slightly enlarged on computed tomography and coronary artery angiography 3 months after the procedure. (e), (f) Computed tomography and coronary artery angiography 10 months after the procedure revealed enlargement of the pseudoaneurysm.
in patients with drug-eluting stents was 4-times higher than that in patients with bare metal stents, suggesting that the complication is associated with drug-eluting stents. Paclitaxel, which is used in the Taxus stent, is an antineoplastic drug from the taxane class, which inhibits cell replication.8 Local inflammatory responses to these drugs may delay the healing process, thus causing aggravated pseudoaneurysm formation after perforation of the coronary vessels. Because we did not perform an intravascular ultrasound examination we
cannot be absolutely sure that this was a pseudoaneurysm. However, the coronary vessel perforation at the initial intervention suggests pseudoaneurysm. The presence of a drug-eluting stent may have contributed to a delay in the healing process, thus resulting in formation of the re-enlarging coronary pseudoaneurysm. Coronary artery injury associated with drug-eluting stents should be carefully observed for possible delays in the healing process, potentially leading to an enlarging pseudoaneurysm.
Downloaded from aan.sagepub.com at ORILLIA CAMPUS LRC on March 17, 2015
Hori et al.
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Figure 3. (a) Intraoperative image showing the right coronary artery pseudoaneurysm. (b) The pseudoaneurysm was opened, revealing the implanted drug-eluting stent. (c) The pseudoaneurysm was closed with a mattress suture, and bypass surgery involving the right epiploic gastric artery was performed.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Bal ET, Thijs Plokker HW, van den Berg EM, Ernst SM, Gijs Mast E, Gin RM, et al. Predictability and prognosis of PTCA-induced coronary artery aneurysms. Cathet Cardiovasc Diagn 1991; 22: 85–88. 2. Ovu¨nc¸ K, Yorgun H and Ozer N. Multiple coronary artery aneurysm formation one year after and four years after sirolimus-eluting coronary stent implantation. Cardiovasc Revasc Med 2009; 10: 252–254. 3. Aqel RA, Zoghbi GJ and Iskandrian A. Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review. Echocardiography 2004; 21: 175–182.
4. Aoki J, Kirtane A, Leon MB and Dangas G. Coronary artery aneurysms after drug-eluting stent implantation [Review]. JACC Cardiovasc Interv 2008; 1: 14–21. 5. Singh H, Singh C, Aggarwal N, Dugal JS, Kumar A and Luthra M. Mycotic aneurysm of left anterior descending artery after sirolimus-eluting stent implantation: a case report. Catheter Cardiovasc Interv 2005; 65: 282–285. 6. Cafri C, Gilutz H, Kobal S, Esanu G, Weinstein JM, AbuFul A, et al. Rapid evolution from coronary artery dissection to pseudoaneurysm after stent implantation: a glimpse at the pathogenesis using intravascular ultrasound. J Invasive Cadiol 2002; 14: 286–289. 7. Hassan AK, Bergheanu SC, Stijnen T, van der Hoeven BL, Snoep JD, Plevier JW, et al. Late stent malapposition risk is higher after drug-eluting stent compared with baremetal stent implantation and associates with late stent thrombosis. Eur Heart J 2010; 31: 1172–1180. 8. Wang D and Gunalingam B. Coronary artery aneurysms associated with a Paclitaxel coated stent. Heart Lung Circ 2008; 17: 66–69.
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