Editor’s Note: This case highlights the innovative device synergy to provide the best long-term results. Use of drug-eluting stents can reduce the reported high restenosis by the use of Jostent graft. One important advise while use of this stent sandwich, will be to have high pressure post dilatation for optimal stent expansion and apposition to reduce stent thrombosis. — Samin K. Sharma, MD, Mount Sinai Medical Center, New York, New York
Case Report. A 72-year-old male patient with hypercholesterolemia, previous smoking, and successful balloon angioplasty at the left anterior descending (LAD) coronary artery 20 years prior was admitted with unstable angina. After medical stabilization, the patient performed a positive stress echocardiography at the left anterior wall.
Coronary angiography showed a severe stenosis at the proximal LAD segment and an aneurysmal dilatation in the mid-LAD segment (Figure 1A, red arrow). An intravascular ultrasound (IVUS; Boston Scientific, Natick, Massachusetts) showed a coronary atherosclerotic aneurysm (CAA), described as a coronary artery dilatation presenting with a broad neck and all three layers of the arterial wall [hence, it was an aneurysm rather than a coronary atherosclerotic pseudoaneurysm (CAP)]. Luminal diameter was 5 x 4 mm at the mid-segment of the LAD (Figure 2A), and minimal cross-sectional area (CSA) at the proximal LAD was 2.8 mm2 (Figure 2B).An ad-hoc percutaneous coronary intervention (PCI) was performed. In order to exclude the CAA from the vessel lumen, a stent-graft was implanted at the mid-segment of the LAD (3.0 x 14 mm Jostent; Abbott Vascular, Redwood City, California), with optimal result both by coronary angiography and by IVUS (Figure 1B, red arrow; Figure 2C). As stent-grafts have a high rate of restenosis, a long drug-eluting coronary stent (3.0 x 28 mm Taxus Liberte coronary stent; Boston Scientific) was implanted, covering not only the severe lesion at the proximal segment of the LAD, but also the segment covered by the stent-graft (in-stent implantation) (Figures 1D and 2D). One-year angiography and IVUS follow-up was performed, showing absence of restenosis and confirming persistence of the exclusion of the CAP. Discussion. CAP represent a rare finding that occurs after surgery coronary bypass, and are mainly located in the distal anastomoses of venous grafts.1 Native coronary arteries are a very uncommon location of CAP, but they may occur after chest trauma or after a coronary dissection during PCI. Currently, the incidence of native-vessel CAP is increasing related to PCI, possibly because of the production of small holes by the guidewire that ultimately generate the expansion of the drilling becoming true contained rupture of the epicardial wall. As our patient had previously undergone a successful balloon angioplasty in the LAD without complications (perforation or dissection), and the IVUS revealed severe atherosclerotic disease in a native artery with the presence of the three arterial wall layers, it is very likely that the patient presented with a CAA rather than CAP. CAA is usually an asymptomatic finding, but they may present with angina or heart failure in case of fistulization to some cavity. Sudden cardiac death due to CAA rupture may also occur, and because of that, these patients are frequently treated with a stent-graft in order to exclude the CAA from the vessel lumen.2 Stent-grafts have an ultra-thin layer of expandable polytetrafluoroethylene placed between two stainless-steel stents, that allow separation of the vessel lumen from the vessel wall. These devices are indicated in some cases of perforation in an epicardial coronary artery during PCI, but also in some selected patients with CAA and CAP. One of the limitations of these devices is a high rate of restenosis, and because of that we decided to implant a drug-eluting coronary stent inside the stent-graft. This strategy has been previously proposed by other investigators,3 and 1-year angiographic and IVUS follow-up confirmed the long-term success of this therapeutic strategy in our patient.
- Alter P, Herzum M, Maisch B. Development of a saphenous vein coronary artery bypass graft pseudoaneurysm. Interact Cardiovasc Thorac Surg. 2004;3:171–173.
- El-Jack SS, Pornratanarangsi S, McNab DC, et al. Percutaneous treatment of a large vein graft aneurysm with covered and conventional stents. Circulation 2006;113:E8–E9.
- Süselbeck T, Haghi D, Borggrefe M, Kaden JJ. Percutaneous treatment of a coronary aneurysm by stent graft and drug-eluting stent implantation: A potential method to reduce stent graft restenosis. J Interv Cardiol 2008;21:325–328.