Case Report

Percutaneous Exclusion of a Giant Coronary Artery Aneurysm Using Two Covered Stents

Jo√£o Carlos Silva, MD and Ricardo Lopes, MD
Jo√£o Carlos Silva, MD and Ricardo Lopes, MD
From the Department of Cardiology, Hospital São João, Porto, Portugal. The authors report no conflicts of interest regarding the content herein. Manuscript submitted November 20, 2008, provisional acceptance given January 7, 2009, final version accepted March 9, 2009. Address for correspondence: João Carlos Silva, MD, Hospital de São João, E.P.E, Laboratório de Hemodinâmica, Alameda Prof. Hernâni Monteiro 4202-451 Porto, Portugal. E-mail: joaocebsilva@hotmail.com

_______________________________________________ ABSTRACT: The treatment of coronary aneurysm (CA) is controversial. Some authors recommend medical treatment, while others favor surgery. Recently, coronary stenting has played an increasingly important role in the treatment of CA. We report a case of a 70-year-old male admitted to our hospital with an acute myocardial infarction of undetermined location (previous known left bundle branch block) and in whom cardiac catheterization showed a proximal 80% stenosis in the left anterior descending artery followed by a giant fusiform CA measuring 18 x 30 mm. We decided to exclude the aneurysm using a covered stent and achieved an excellent angiographic result. Keywords: Acute coronary syndromes; angioplasty; coronary interventions; stenting; coronary angiography

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J INVASIVE CARDIOL 2009;21:E119–E121 Case Description A 70-year-old male, obese and a former smoker, was admitted with an acute myocardial infarction (AMI). He had history of arterial hypertension, hyperlipidemia, cerebrovascular disease (stroke in 2004, left inferior limb paresis as sequela), GOLD IV chronic obstructive pulmonary disease (COPD), drained subdural hematoma after a brain trauma in 1998 and surgery of an abdominal aortic aneurysm in 2002. The AMI was of undetermined location (previous known left bundle branch block) and the patient was asymptomatic at admission. The maximum troponin I value was 8.41 ng/ml and he was treated with tirofiban. The transthoracic echocardiogram (poor acoustic window) showed severely depressed left ventricular (LV) systolic function and an apical aneurysm. Cardiac catheterization showed a dilated LV with severely depressed contractility and an apical aneurysm. The left main (LM), circumflex (Cx) and right coronary (RCA) arteries had no significant disease. The left anterior descending (LAD) artery had a proximal 80% stenosis followed by a giant fusiform coronary aneurysm (CA) measuring 18 x 30 mm. The aneurysm had an abrupt onset and a cone-shaped end just before the bifurcation of the first diagonal (DG1) (Figures 1 A and B). As the patient was a poor surgical candidate due to his respiratory disease, we used a percutaneous approach, excluding the CA with covered stents. A 7 Fr JL5 catheter (Cordis Corp., Miami Lakes, Florida) was used. A 0.014 inch Runthrough (Terumo Medical Corp., Somerset, New Jersey) was passed through the lesion and the CA, and the proximal lesion was predilated using a 3 mm balloon (Ryujin, Terumo). As the longest covered stent available (26 mm) was unable to exclude the aneurysm, we decided to implant 2 covered stents (GraftMaster 4 x 26 mm, Abbott Vascular Abbott Park, Illinois). One over the proximal stenosis was placed proximally in order to obtain a good anchor, as its distal part would have no support. Six-to-seven mm of the proximal LAD were left uncovered in an attempt to avoid the extension of a possible restenosis in the LM artery. The second stent was placed distally, superposed with the first one (6 mm) and with the distal end before the DG1 bifurcation, producing an excellent angiographic result. The distal flow was normal and no flow to the aneurysm was seen (Figures 2 C and D). After device implantation, the patient complained of chest pain attributed to the occlusion of the septal branches that originated from the treated segment. The procedure had no immediate complications. The patient had a slight increase of troponin I to 4.012 ng/ml and was discharged 4 days after percutaneous intervention. In the following 6 months, he was free from angina and other ischemic events. Angiographic control imaging at 6 months showed no significant restenosis (Figures 3 E and F). CAs are found in 0.3–5 % of patients undergoing coronary angiography. The most common cause of CA is atherosclerosis, but they may also be congenital, mycotic or arise as part of systemic inflammation.1 They usually have no associated symptoms, however, they may present with ischemic symptoms (angina or AMI) or sudden death. Possible complications are compression, thrombus formation, distal embolization and rupture. The optimal treatment of CA is a matter of debate. Some authors recommend medical treatment (anticoagulants and/or antiplatelets agents), while others prefer surgery (bypass graft with or without resection or ligation of the CA).2 There appears to be a consensus, however, that a CA measuring at least three or four times the size of the normal vessel is an absolute indication for surgical intervention due to the elevated risk of complications.1,3 Recently, coronary stenting has played an increasingly important role in the treatment of CA.4 Our patient presented with an atherosclerotic CA, probably secondary to a previous plaque rupture. Since this CA was located in a coronary artery that supplied an already infarcted myocardial territory, the decision to exclude it was based on its enormous dimension (> 4 times the size of the original vessel diameter) and the inherent high risk of rupture. The surgical contraindication (COPD) led us to exclude the CA percutaneously using 2 covered stents.

References
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4. Bartoreili AL, Grancini L, Montorsi P, et al. Large coronary aneurysm Complicated by acute myocardial infarction: Combined intravascular ultrasound imaging and doppler flow assessment before and after PTFE-covered stent implantation. J Invasive Cardiol 2002;14:452–456.