J INVASIVE CARDIOL 2018;30(5):E42-E43.
Key words: aneurysm, PTFE-covered stent, GraftMaster
A 70-year-old man with hypertension, diabetes, chronic obstructive pulmonary disease, left ventricular ejection of 40%, and history of renal transplant presented to the emergency department with NSTEMI. Left heart catheterization revealed tandem 90% lesions of the RCA with adjacent, large saccular aneurysms (Figure 1; Videos 1 and 2). PCI was planned excluding the aneurysmal segments using Jostent GraftMaster PTFE-covered stents (Abbott Vascular). Given that the maximal length (26 mm) and diameter (4.8 mm) of the covered stents were felt to be insufficient for stable implantation into the aneurysmal segments, we planned on placing standard drug-eluting anchoring stents prior to GraftMaster implantation.
After engaging the RCA with an AL guide catheter, an 8 Fr GuideLiner (Vascular Solutions) was placed for additional support. IVUS was performed, revealing distal aneurysm with maximal diameter of 7.8 mm and proximal aneurysm with maximal diameter of 7.0 mm (Figure 2; Video 3). Predilation was performed with a 2.5 x 40 mm Apex balloon (Boston Scientific) at 12 atm. A 2.75 x 38 mm Synergy stent (Boston Scientific) was placed at 14 atm across the distal part of the second aneurysm into the posterolateral branch of the RCA. We then stented from the distal to proximal RCA with three 4.0 x 38 mm Synergy stents (inflated at 11, 18, and 12 atm, respectively), sparing the ostium. Notably, following this initial stenting, the proximal aneurysm appeared successfully excluded, although the distal aneurysm continued to show blood flow. Using the stent balloon, we then tracked the GuideLiner to the distal RCA (Figure 3A; Video 4). Through the GuideLiner, we passed a 4.0 x 19 mm GraftMaster into the distal aneurysm and inflated at 16 atm (Figure 3B; Video 5). The aneurysm was still not completely excluded, so an additional 4.0 x 16 GraftMaster was placed at 18 atm proximal to the prior covered stent, resulting in successful exclusion of aneurysmal blood flow (Figure 3C; Video 6). We then postdilated the posterolateral branch stent with a 3.5 x 27 mm non-compliant (NC) balloon at 18 atm. Subsequent postdilations to the remaining RCA stents were performed with a 4.5 x 20 mm NC balloon using inflations ranging from 14-18 atm. Lastly, we stented the ostial RCA with a 4.0 x 18 mm Xience stent (Abbott Vascular), and postdilated with a 4.5 x 20 mm NC balloon at 14 atm, with good final angiographic result (Figure 3D; Video 4). The patient was discharged the following day with plans for at least 1 year of aspirin and clopidogrel.
Various methods have been proposed for the treatment of coronary aneurysms. We demonstrate a novel technique to safely exclude long aneurysmal segments that require multiple covered stents in a single segment. In addition, we demonstrate the usefulness of balloon-assisted GuideLiner tracking to pass bulky equipment to the distal segments of heavily diseased vessels.
View the accompanying Video Series here.
From Cleveland Clinic, Department of Cardiovascular Medicine, Cleveland, Ohio.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted February 8, 2018.
Address for correspondence: Jeffrey Rossi, MD, Cleveland Clinic, J3-6, 9500 Euclid Avenue, Cleveland, OH 44195. Email: Rossij4@ccf.org