Management of coronary artery rupture: covered stent or microcoil embolization

Diagnosis and treatment of spontaneous coronary artery pseudoaneurysm: Rare anomaly with potentially significant clinical implications

Spontaneous coronary artery pseudoaneurysm (PSA, false aneurysm) is an extremely rare occurrence with the precise incidence unknown. It is defined as an outwardly bulging monolayer or double layer within the coronary artery that lacks all 3 layers (intima, media, and adventitia) of the arterial wall. Coronary PSA commonly occurs from arterial dissection or perforation induced by catheter intervention, infection, pregnancy, or trauma. Traumatic dissection or perforation of the coronary artery after a percutaneous coronary intervention (PCI) remains the most common cause. Such cases may progress to myocardial ischemia, acute myocardial infarction, or acute coronary artery rupture causing death from cardiac tamponade. Intravascular ultrasound or cardiac computed tomography may aid in the diagnosis. Treatment options include PCI with a covered stent, bare or drug-eluting stent, coil embolization, coronary artery bypass graft with isolation of the PSA, or conservative management with vigilant clinical follow-up. In this review, we sought to describe the diagnosis, etiology, treatment, and the limited literature on spontaneous coronary artery PSA. © 2017 Wiley Periodicals, Inc.

Hemopericardium Due to Idiopathic Coronary Artery Rupture Treated with Saphenous Vein Patch Plasty

We report a case of an idiopathic coronary artery rupture in a 41-year-old male patient who was admitted to the hospital with cardiac tamponade. On opening the chest via a median sternotomy and establishing cardiopulmonary bypass the hemopericardium's cause could be identified as a perforation of the right posterior descending coronary artery which was treated with a saphenous vein patch plasty. With idiopathic coronary artery rupture being a rare diagnosis, one should always consider it in a young patient presenting with cardiac tamponade.

Double Guide Catheter Technique for Sealing an Iatrogenic Coronary Perforation

Introduction:

Coronary vessel perforation is one of the most feared complications of coronary angioplasty. The treatment of this complication relies mostly on the implantation of covered stents. However, due to their design, covered stents are difficult to advance in a tortuous or calcified vessel.

Case Presentation:

We present a case of a grade III coronary perforation in which the double guiding catheter technique helped us to deliver the graft stent.

Conclusions:

The double-guiding technique is useful in emergency situations to increase the safety and efficacy of sealing a coronary perforation.

Balloon Occlusion Types in the Treatment of Coronary Perforation during Percutaneous Coronary Intervention

Coronary artery perforation is an uncommon complication in patients with coronary heart disease undergoing percutaneous coronary intervention. However, pericardial tamponade following coronary artery perforation may be lethal, and prompt treatment is crucial in managing such patients. Balloon occlusion and the reversal of anticoagulant activity are the common methods used to prevent cardiac tamponade by reducing the amount of bleeding. Herein, we discuss the pros and cons of currently used occlusion types for coronary perforation. Optimal balloon occlusion methods should reduce the amount of bleeding and ameliorate subsequent myocardial ischemia injury, even during cardiac surgery.

A unique and unexplained ricochet leak post PCI - successfully treated with intra-coronary glue

We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate.

Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, management, and clinical outcomes in patients with grade III coronary perforation during percutaneous coronary intervention.

BACKGROUND

Grade III coronary perforation is a rare but recognized complication associated with high morbidity and mortality.

METHODS

From 24,465 patients undergoing percutaneous coronary intervention from May 1993 to December 2009, 56 patients had grade III coronary perforation.

RESULTS

Most lesions were complex: 44.6% type B2, 51.8% type C, and 28.6% chronic total occlusions, and within a small vessel (≤ 2.5 mm) in 32.1%. Glycoprotein IIb/IIIa inhibitors were administered in 17.9% of patients. The device causing perforation was intracoronary balloon in 50%: 53.6% compliant, 46.4% noncompliant; intracoronary guidewire in 17.9%; rotablation in 3.6%; and directional atherectomy in 3.6%. Following perforation, immediate treatment and success rates, respectively, were prolonged balloon inflation 58.9%, 54.5%; covered stent implantation 46.4%, 84.6%; coronary artery bypass graft surgery (CABG) and surgical repair 16.0%, 44.4%; and coil embolization 1.8%, 100%. Multiple methods were required in 39.3%. During the procedure (n = 56), 19.6% required cardiopulmonary resuscitation and 3.6% died. In-hospital (n = 54), 3.7% required CABG, 14.8% died. The combined procedural and in-hospital myocardial infarction rate was 42.9%, and major adverse cardiac event rate was 55.4%. At clinical follow-up (n = 46) (median: 38.1 months, range 7.6 to 122.8), 4.3% had a myocardial infarction, 4.3% required CABG, and 15.2% died. The target lesion revascularization rate was 13%, with target vessel revascularization in 19.6%, and major adverse cardiac events in 41.3%.

CONCLUSIONS

Grade III coronary perforation is associated with complex lesions and high acute and long-term major adverse cardiac event rates.

Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention

Coronary artery perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention. There are limited controlled contemporary data regarding its predictors, incidence, and outcomes. The aim of this study was to define the incidence, associated factors, and outcomes of CP in the current era of coronary intervention. All patients who had CP during percutaneous coronary intervention at a large tertiary center from January 2001 to December 2008 were identified. Demographic, clinical, and procedural data and outcome variables were obtained. Patients with CP were compared with a randomly assigned control group. Fifty-seven patients with CP were identified among 9,568 interventions performed during the study period (0.59%); these patients were compared with 171 who underwent percutaneous coronary intervention without CP. Vessels were perforated by wires (52.6%), balloons (26.3%), and stents (21.1%). Perforations were classified using the Ellis classification. CP was associated with mortality and tamponade rates of 7% and 16%, respectively, but all these serious complications occurred with grade III perforations. Most grade I and II perforations were managed conservatively. Multivariate analysis identified the treatment of chronic total occlusion as the strongest independent predictor of CP; other independent variables included calcium in the coronary artery that was the site of intervention and non-ST elevation myocardial infarction.

Use of stent grafts and coils in vessel rupture and perforation

Vessel rupture and perforation are important complications of percutaneous treatment of coronary and peripheral arterial disease. These complications can result in abrupt vessel closure, distal organ injury, bleeding into the surrounding tissue, and death. Prompt management of such complications is therefore critically important. This paper reviews the management of vessel rupture and perforation, including the use of different types of covered stents (balloon-expandable and self-expanding), as well as the various types of embolization coils. Particular focus will be placed on percutaneous coronary artery and peripheral arterial interventions.

Search your heart for a cause of syncope!

A 66-year-old female presented to casualty with recurrent syncopal episodes and a history of ischaemic heart disease. Initial investigations did not provide a definitive diagnosis. Subsequent CT scanning identified a giant pseudoaneurysm of the left anterior descending coronary artery, which is the largest reported to date. We include a short discussion on current literature surrounding coronary artery pseudoaneurysmal disease.

Coil embolization of a circumflex coronary aneurysm at the time of percutaneous coronary stenting

Coronary atherosclerotic aneurysm often occurs in association with severe atherosclerotic coronary stenosis. We describe the percutaneous catheter-based approach to coil embolization of a circumflex coronary aneurysm at the time of obtuse marginal branch coronary stent deployment.

Eight-year clinical and angiographic follow-up after implantation of autologous arterial graft covered stent in a de novo thrombus-containing lesion

In this case report, we present the clinical and angiographic follow-up 8 years after implantation of autologous arterial graft covered stent in a thrombus-containing lesion in the proximal segment of left anterior descending artery. The patient was asymptomatic after the implantation of the covered stent until 2 months prior to the coronary angiography. In the repeat angiography, the left anterior descending artery was patent at the site of the covered stent implantation. At the proximal and distal sites of the covered stent, there was no restenosis. In this case report, there were no long-term technique-related complications after the successful autologous arterial covered stent deployment.

Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review

Spontaneous coronary artery dissection is a rare cause of myocardial ischemia and sudden death. Coronary aneurysms and pseudoaneurysms, which may occur after percutaneous coronary interventions, rarely occur spontaneously. We review the pertinent medical literature and describe the intravascular findings of spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms.

Large pseudoaneurysm after left main trunk stenting sealed by polytetrafluorethylene-covered stent

Left main trunk (LMT) aneurysm is very rare and the management remains uncertain. We describe a patient who developed a pseudoaneurysm from coronary perforation during stent implantation in LMT and was then treated with polytetrafluorethylene (PTFE)-covered stent graft. PTFE-covered stent is considered to be a valid strategy for LMT aneurysms.

Occlusion of a saphenous vein graft aneurysm with a vein-covered stent

A 67-year-old man was admitted with unstable angina, 15 years after saphenous vein graft bypass surgery. Cardiac catheterization demonstrated a large saccular aneurysm arising from the proximal segment of the vein graft to the obtuse marginal artery. Intravascular ultrasound revealed the opening of the aneurysm that measured 15 mm in length. The aneurysm was successfully occluded by deployment of a vein-covered stent.

New stent design for autologous venous graft-covered stent preparation: first human application for sealing of a coronary aneurysm

In this case report, we present the first clinical application of a new stent design for autologous venous graft-covered stent preparation. This stent consists of a main body, resembling the configuration of conventional stents, and two connecting arms at the edges of the stent for the stabilization of the venous graft on the external surface of the stent. This new stent design was applied in a patient with an aneurysm in a stented segment in the right coronary artery. The immediate and long-term angiographic evaluation after the covered stent implantation showed complete sealing of the aneurysm without restenosis.

Successful long-term therapy following saphenous vein-covered stent deployment for atherosclerotic coronary aneurysm

We describe a case of atherosclerotic aneurysm involving the left main coronary artery in a patient with prior coronary artery bypass surgery. A saphenous vein-covered stent was used to seal the aneurysm in conjunction with conventional stenting of an associated native vessel coronary stenosis. Focal late restenosis involving the stent graft was successfully treated with repeat angioplasty and brachytherapy. Autologous vein-covered stent deployment should be considered in the treatment of symptomatic or progressively enlarging coronary aneurysms.

Coil embolization for successful treatment of perforation of chronically occluded proximal coronary artery

We describe a case of a coronary artery perforation involving the proximal right coronary artery that was successfully managed by percutaneous coil embolization. In the setting of a chronic coronary artery occlusion, this demonstrates the successful use of thrombogenic platinum alloy coils for a large proximal vessel perforation which has not been described previously.

Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management

Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.

Successful treatment of coronary artery perforation in an abciximab-treated patient by microcoil embolization

We describe a case of type 2 coronary artery perforation in a 73-year-old man undergoing coronary artery rotablation and stenting with abciximab therapy. The coronary artery perforation was successfully treated by coil embolization with Trufill pushable coils made from platinum alloy and synthetic fibers to promote maximum thrombogenicity.

Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.

Left internal mammary artery graft perforation repair using polytetrafluoroethylene-covered stents

The increase in the use of the left internal mammary artery (LIMA) as graft of choice to the left anterior descending coronary artery for conventional and minimally invasive coronary artery bypass surgery has led to an increased incidence of LIMA pathologic lesions early after surgery. The lesion, commonly located in the body of the LIMA graft, is usually caused by mechanical injury during harvesting of the vessel. In this context, percutaneous intervention with stent implantation can be complicated by vessel rupture, which usually requires emergency surgical repair. We describe two cases of stent implantation in newly placed LIMA grafts complicated by vessel rupture, which were successfully repaired using polytetrafluoroethylene-covered stents.

Stents covered by autologous venous grafts: feasibility and immediate and long-term results

BACKGROUND

Previous experimental studies with a new covered stent, the autologous venous graft-covered stent (AVGCS), have shown favorable results. The aim of this study was to evaluate the feasibility and safety of this new technique in human coronary arteries and to compare the long-term outcome with uncovered stents.

METHODS AND RESULTS

A venous graft was removed from an upper limb. A conventional stent then was covered by the venous graft. Fifty-eight AVGCS were implanted in 56 patients, including 16 patients with acute coronary syndromes (ACS). Additionally, in 114 patients, 138 uncovered stents were implanted, serving as a control group, including 38 patients with ACS. The procedure was successful in all patients. Stent thrombosis was observed in 3 patients in the control group and in 1 patient with an AVGCS. There was a trend for the minimal luminal diameter to be greater in the AVGCS group at follow-up (P =.07), and statistical significance was observed in patients with ACS (P <.01). The target vessel revascularization and the restenosis rates were similar between the 2 groups. In patients with ACS, the restenosis rate was less (P <.04) and there was a trend for target vessel revascularization to be less in covered stents (P =.09). The event-free survival rate at 4 years was 85% in the AVGCS group versus 81% in the control group (P = not significant); in ACS it was 94% versus 78%, respectively (P = not significant). Stents covered by thicker venous grafts were associated with improved clinical outcome.

CONCLUSIONS

Stents covered by autologous venous grafts may be safely prepared without complications. This technique may prove to be a useful means, especially in patients with ACS.

Gelfoam embolization of a distal coronary artery guidewire perforation

A guidewire-induced distal coronary artery perforation presenting with cardiac tamponade was occluded by distal Gelfoam embolization via an infusion catheter. This extends the treatment options for this rare complication of coronary interventional procedures. Cathet. Cardiovasc. Intervent. 49:214-217, 2000.

Repair of left anterior descending coronary artery perforation by Magic Wallstent implantation

Coronary rupture is a rare complication of percutaneous coronary intervention. However, it may be associated with serious hemodynamic consequences often leading to tamponade, myocardial infarction, emergency surgical intervention, or death. We report a successful percutaneous repair of a brisk left anterior descending coronary artery perforation by the implantation of a Magic Wallstent.

Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction

We describe the occurrence of a localized saccular pseudoaneurysm in a 69-year-old patient 2 weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. The therapy of perforations requires prolonged balloon inflations, perfusion balloons, covered stents, or surgery. Coronary peudoaneurysm formations are rare; their therapy requires covered stents or surgery. Cathet. Cardiovasc. Intervent. 47:341-346, 1999.

Left internal mammary artery graft perforation due to high-pressure stent deployment

Perforation of newly placed left internal mammary artery (LIMA) grafts due to stent deployment is an infrequent but potentially dangerous complication of coronary interventions. It may lead to brisk hemorrhage and massive cardiac tamponade requiring emergent pericardiocentesis and surgery. We report a case of a LIMA graft perforation following stent deployment with a high-pressure balloon 12 days after surgery. The patient was treated with emergent pericardiocentesis, rapid autotransfusion of the pericardial aspirate into the systemic circulation, and surgical repair of the ruptured vessel.

Therapeutic embolization for unusual latrogenic complications related to coronary revascularization

Percutaneous therapeutic embolization may be an effective strategy to manage distal coronary perforations or inadvertent iatrogenic coronary arteriovenous fistula complicating revascularization procedures. We present two cases in which embolization techniques were used to manage these patients and avoid the need for surgical intervention.

Successful closure of coronary-bronchial artery fistula with vein graft-coated stent

A coronary-bronchial fistula and aneurysmal dilatation of the proximal part of the fistula was successfully closed using an autologous vein graft-coated stent (Palmaz-Schatz stent). This is the first report that demonstrates the feasibility of the vein-coated stent for the treatment of congenital disease.

Coronary vessel perforation during balloon angioplasty: a case report

Coronary perforation can be managed with prolonged balloon inflations, covered stents, or embolization of the vessel. We report on a case of a balloon-induced perforation of the distal left anterior descending artery, that was sealed by injecting preclotted autologous blood through the balloon catheter lumen at the site of the perforation. The patency of the distal vessel was maintained.

Acute directional coronary atherectomy prior to stenting in complex coronary lesions: ADAPTS Study

The purpose of this study was to determine the results of directional coronary atherectomy (DCA) combined with stenting in a high-risk patient population. The use of stenting or DCA alone for aorto-ostial lesions, total chronic occlusions, long lesions, and lesions containing thrombus is associated with lowered success and a relatively high restenosis rate. Between July 1993 and October 1996, we treated 89 lesions with the combined approach of DCA and stenting in 60 consecutive patients. Thirty-one (51.7%) patients were treated because of unstable angina, 11 (18.3%) for post-myocardial infarction (MI) angina, 3 (5.0%) for acute MI, and 15 (25.0%) patients for stable angina. A total of 43 (71.7%) patients had multivessel disease, 19 (31.7%) had undergone previous coronary artery bypass graft (CABG), and 17 (28.3%) patients had undergone multivessel revascularization. The procedure was successful in all patients; and no postprocedural deaths or emergent CABG occurred. Two patients (3.3%) had non-Q-wave MI after the procedure and 1 patient (1.7%) experienced Q-wave MI due to subacute stent closure 7 days after the procedure. During follow-up ranging from 6 months to 3 years, 2 (3.3%) patients died, 2 (3.3%) required CABG surgery, 1 (1.7%) patient had an MI, and 6 patients (10.0%) required target vessel revascularization. By the quantitative coronary angiography, the initial minimal luminal diameter (MLD) averaged 0.91+/-0.45 mm (74.7+/-11.8% stenosis) increasing to 3.80+/-0.44 mm (-6.7+/-12.1%) after the combined approach procedure. Thirty patients (50.0%) met criteria for late (> or =6 months) angiographic follow-up. Late MLD loss averaged 1.13+/-1.07 mm, for a mean net gain of 1.61+/-1.23 mm. Available angiographic follow-up evaluation showed a restenosis rate of 13.3%. A combined approach, defined as the use of both DCA and stenting, is safe and yields a low restenosis rate in high-risk patients who have lesions known to respond less favorably to stenting or DCA alone.

[Perforation and rupture of coronary arteries]

Spontaneous rupture of coronary arteries as well as coronary perforation during percutaneous interventions are rare but potentially life-threatening incidents often resulting in emergency surgery. Frequency of acute perforation due to therapeutic catheterization varies according to the devices employed. With conventional balloon angioplasty it is estimated to be 0.1 to 0.2% whereas substantially higher rates of up to 3% have been reported with the use of so-called "new devices" (i.e. directional atherectomy, rotablation, excimer laser angioplasty or extractional atherectomy). Interventional strategies for nonsurgical treatment of acute coronary perforations during catheterization procedures have been developed. In recent times, availability of coronary stent-grafts allows for a percutaneous resolution of acute perforations while maintaining vessel patency. Whereas iatrogenic perforations in the catheterization laboratory may thus be treated immediately at the site of their occurrence, rupture of pre-existing but potentially unknown coronary pathology frequently is associated with a diagnostic interval, giving rise to serious clinical events (i.e. myocardial infarction, cardiac tamponade, malign arrhythmias or sudden death). It may be warranted to advocate prophylactic treatment of rupture-prone coronary conditions even on incidental diagnosis. This can either be performed by cardiothoracic surgery or, in suitable cases, by interventional therapy. Implantation of coronary stent-grafts could prove to become the therapy of choice due to its technical facility, safety and the short length of hospital stay associated with it. Before general recommendations can be made, however, as to the extension of indication for these novel coronary devices, further clinical studies encompassing long-term clinical and angiographic follow-up are needed.

Development of coronary aneurysm after cutting balloon angioplasty: assessment by intracoronary ultrasound

We report the case of a coronary aneurysm observed 6 mo after cutting balloon angioplasty complicated by a mild perforation. Intravascular ultrasound allowed characterization of the malformation as a true aneurysm. The clinical course was uneventful.

Immediate results and dilatation effect of the vein-covered Palmaz-Schatz stent assessed by intravascular ultrasound

To evaluate the clinical results of stenting using the vein-covered Palmaz-Schatz (PS) stent by intravascular ultrasound (IVUS). Twenty-eight patients with angina pectoris or confirmed ischemia were entered into this study. Thirteen were allocated to the vein-covered PS stent group and 15 to the normal Palmaz-Schatz stent group. The immediate clinical results in these groups and changes in lumen dimension as assessed by IVUS, were investigated. Acute success was 100% in both groups. There were no immediate complications. Subacute thrombosis occurred in one patient in the vein-covered PS group. In the vein-covered PS group, percent diameter stenosis of the involved coronary artery changed from 70.2% before stenting to 8.8% immediately after and 42.2% at 5 months follow-up. The respective values were 84.5%, 13.4%, and 36.5% in the normal Palmaz-Schatz group. Restenosis in the vein-covered group was 23.1% and in the Palmaz-Schatz group was 20%, showing no significant differences between the two groups. The luminal area in the vein-covered group as assessed by IVUS increased from 3.2 mm2 to 7.4 mm2 (pre to post) and from 3.2 mm2 to 8.2 mm2 in the normal Palmaz-Schatz group. The plaque area decreased from 13.6 mm2 to 10 mm2 (pre to post) in the vein-covered group and from 13.0 mm2 to 9.2 mm2 in the Palmaz-Schatz group. In this study, conducted in a limited number of cases, it is possible to use vein-covered stent like as usual Palmaz-Schatz stent. The vein-covered stent had less dilative effect compared with the Palmaz-Schatz stent. This was probably because of its increased profile but there was no difference in the occurrence of subacute thrombosis or in restenosis rate.

Distal coronary artery perforation resulting from the use of hydrophilic coated guidewire in tortuous vessels

We describe our experience with the ChoiCE PT (Boston Scientific Corporation, MN) guidewire, which resulted in perforation of the distal coronary artery in two instances. This newly introduced guidewire differs from earlier guidewires in its ability to cross lesions in tortuous arteries. However, when it buckles deep in the coronary artery, perforation can easily result. While the ChoiCE PT guidewire is a useful addition to our armamentarium in interventional procedures, it should be treated with care.

Coronary artery perforation repair using microcoil embolization

An 82-year-old woman undergoing percutaneous transluminal coronary angioplasty experienced perforation of the terminal portion of the left anterior descending coronary artery caused by guidewire trauma. The coronary artery perforation was successfully closed using a vascular occlusion system consisting of individual thrombogenic coils delivered to the site. Coronary artery perforation (CAP) during percutaneous transluminal coronary angioplasty (PTCA) has been reported to occur in less than 1% of cases. The incidence seems to be higher with the new interventional devices, e.g., DCA, TEC, and laser CAP may result in pericardial hemorrhage and cardiac tamponade or a coronary artery fistula to either the left or right ventricle. The management of CAP may include prolonged balloon inflations, reversal of anticoagulation, pericardiocentesis, and emergency surgery. Proximal perforations sometimes can be managed with vein covered stents. We describe another option in the treatment of distal CAP using a vascular occlusion system.

Autologous vein-covered stent repair of a cervical internal carotid artery pseudoaneurysm: technical case report

OBJECTIVE AND IMPORTANCE

Stenting of a cervical internal carotid pseudoaneurysm is presented using a stent covered with saphenous vein. This procedure resulted in immediate exclusion of the aneurysm and maintained patency of the carotid artery.

CLINICAL PRESENTATION

A gunshot to the neck resulted in airway obstruction and respiratory arrest with neurological injury in a male patient. Angiographic investigation revealed an enlarging cervical internal carotid pseudoaneurysm, possibly the source of a cerebral embolism. Anticoagulation had to be stopped because of bleeding complications. A decision was made to conduct definitive percutaneous treatment of the pseudoaneurysm.

TECHNIQUE

A Palmaz stent (JJIS, Warren, NJ) was covered with saphenous vein harvested from the patient's leg. Using standard technique and a simple innovation for stent construct introduction into the sheath, the vein-covered stent was placed across the opening of the aneurysm and dilated into position with a balloon.

CONCLUSION

Immediate exclusion of a cervical internal carotid pseudoaneurysm was performed using an autologous vein-covered stent. One-month follow-up confirmed continued exclusion of the pseudoaneurysm and carotid patency without stenosis.

Arterial autologous graft-stent for treatment of coronary artery disease: a new technique

The radial artery has been used as a free bypass graft with excellent results. An autologous vein graft-coated stent, a novel type of stent developed at our institution, has been applied successfully under both experimental and clinical conditions. To extend the spectrum of biological linings for coated stents, we used an arterial graft. We describe the first application of the radial artery as an autologous coating for a conventional stent to be used in treatment of coronary artery disease.

Autologous vein graft-coated stents for the treatment of thrombus-containing coronary artery lesions

Recent studies have shown that stents may have a potential role in the treatment of thrombus-containing lesions. We report on the application of an autologous vein graft-coated stent (AVGCS) as the primary therapeutic modality for acute myocardial infarction in 10 patients. AVGCS delivery and deployment were successful and uneventful. Mean minimal lumen diameter and TIMI trial flow grade increased significantly (from 0.04 +/- 0.09 mm pre-AVGCS to 3.02 +/- 0.32 mm post-AVGCS, and from 10 patients with flow grade 0-1 pre-AVGCS to 10 patients with flow grade 3 post-AVGCS, respectively). Ten-day angiogram revealed maintenance of the immediate results. Nine patients had a negative exercise stress test 2 mo post-AVGCS, and at a mean follow-up of 30 +/- 7 weeks, all 9 were symptom-free. One patient, 3 wk after implantation and while being hospitalized for hypovolemic shock, developed recurrent infarction. These favorable preliminary outcomes suggest that AVGCS may play a useful role in the treatment of thrombus-containing lesions.

Percutaneous revascularization of an extensively diseased saphenous vein bypass graft with a saphenous vein-covered Palmaz stent

A 68-year-old man developed unstable angina 12 years following coronary artery bypass surgery. Angiography revealed an extensive area of severe stenosis and diminished distal flow in a right coronary artery vein bypass graft. Given the high distal embolism rate associated with conventional catheter-based treatment of old degenerated vein grafts, the diseased area was "relined" with a composite autologous saphenous vein-covered stent. The procedure was performed using modifications of standard PTCA methods and resulted in a widely patent, smooth lumen. This initial case demonstrates that a degenerated saphenous vein graft can be successfully revascularized with an autologous saphenous vein-covered stent in an attempt to minimize the potential complications of standard catheter-based revascularization methods.