Systematic review of the evaluation and management of coronary pseudoaneurysm after stent implantation

A case report of a rapidly growing giant coronary pseudoaneurysm: challenges and lessons learned

Background

Coronary pseudoaneurysm is a rare, potentially fatal, complication of coronary intervention. A challenging management case of a giant right coronary pseudoaneurysm is presented.

Case summary

A 56-year-old man presented with an atypical presentation for ST-elevation myocardial infarction. Initial angiogram showed a crescent-shaped ostial lesion with probable connection to the aorta, which disappeared after placing a drug-eluting stent. A few hours later, patient was found to have staph aureus bacteraemia and infective endocarditis for which he received a prolonged antibiotic course. Patient presented a few weeks later with second degree heart block. Echocardiography showed a large cystic lesion adjacent to the right coronary cusp suspicious for a coronary pseudoaneurysm, which was confirmed with angiography. Attempts to treat it with a covered stent were unsuccessful and patient ultimately underwent surgical resection.

Discussion

Coronary pseudoaneurysm develops when there is a contained breach of all three layers of the vessel. It may develop from direct iatrogenic trauma to the vessel wall but can be infectious in aetiology. The treatment approach remains uncertain due to limited evidence. Here, we present the diagnostic and technical challenges of managing such an uncommon entity and discuss an algorithm for management.

Treatment of coronary pseudoaneurysm detected after percutaneous coronary intervention for chronic total occlusion: A case report

BACKGROUND

Coronary pseudoaneurysm (CPA) are associated with iatrogenic coronary artery dissection or perforation, which rarely reported formation early after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study reported a case of CPA that developed 4 weeks after PCI for CTO.

CASE REPORT

A 40-year-old man was admitted with unstable angina and diagnosed with CTO of the left anterior descending artery (LAD) and right coronary artery. The CTO of the LAD was successfully treated by PCI. However, reexamination by coronary arteriography and optical coherence tomography after 4 weeks confirmed a CPA at the stented middle segment of the LAD. The CPA was treated surgically by the implantation of a Polytetrafluoroethylene-coated stent. reexamination at the 5-month follow-up revealed a patent stent in the LAD and no CPA-like manifestations. Intravascular ultrasound showed no intimal hyperplasia or in-stent thrombogenesis.

CONCLUSION

CPA might develop within weeks after PCI for CTO. While it could be successfully treated by the implantation of a Polytetrafluoroethylene-coated stent.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

Coronary artery ectasia (CAE) is defined as a diffuse or focal dilation of an epicardial coronary artery, which diameter exceeds by at least 1. 5 times the normal adjacent segment. The term ectasia refers to a diffuse dilation, involving more than 50% of the length of the vessel, while the term aneurysm defines a focal vessel dilation. CAE is a relatively uncommon angiographic finding and its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography. Although its pathophysiology is still unclear, atherosclerosis seems to be the underlying mechanism in most cases. The prognostic role of CAE is also controversial, but previous studies reported a high risk of cardiovascular events and mortality in these patients after percutaneous coronary intervention. Despite the availability of different options for the interventional management of patients with CAE, including covered stent implantation and stent-assisted coil embolization, there is no one standard approach, as therapy is tailored to the individual patient. The abnormal coronary dilation, often associated with high thrombus burden in the setting of acute coronary syndromes, makes the interventional treatment of CAE patients challenging and often complicated by distal thrombus embolization and stent malapposition. Moreover, the optimal antithrombotic therapy is debated and includes dual antiplatelet therapy, anticoagulation, or a combination of them. In this review we aimed to provide an overview of the pathophysiology, classification, clinical presentation, natural history, and management of patients with CAE, with a focus on the challenges for both clinical and interventional cardiologists in daily clinical practice.