Author + information
- Sanjay C. Shah, MD, DMa,
- Tejas M. Patel, MD, DMa,
- Gaurav A. Patel, MDb and
- Samir B. Pancholy, MDb,∗ ()
- aApex Heart Institute, Ahmedabad, India
- bThe Wright Center for Graduate Medical Education, Scranton, Pennsylvania
- ↵∗Address for correspondence:
Dr. Samir B. Pancholy, The Wright Center for Graduate Medical Education, 401 North State Street, Clarks Summit, Pennsylvania 18411.
Although covered stents have been available for percutaneous treatment of coronary aneurysms, patients with longer aneurysmal segments have been difficult to treat with covered stents. The authors describe a case of a right coronary artery aneurysm with an angiographically estimated length exceeding 30 mm treated percutaneously using covered stents and conventionally available hardware. (Level of Difficulty: Advanced.)
Coronary artery aneurysms, defined as greater than a 1.5-fold increase in the diameter of the coronary lumen compared with the adjacent reference lumen, have been observed in 0.3% to 4.9% of patients referred for coronary angiograms (1). The etiologies range from atherosclerotic degeneration, which is the most common etiology, to genetic disorders as well as inflammatory conditions that lead to coronary artery aneurysm formation. Although the natural history of these aneurysms is largely unknown, a 2- to 4-fold higher incidence of major adverse cardiovascular events (2) raises concern in younger patients with both patient and provider preference for mechanical exclusion of aneurysmal segments either percutaneously or surgically if the procedural risks are acceptable. Percutaneous management has included the use of covered stents with or without coil embolization. Covered stents with sizes suitable for coronary use have been available with lengths ranging from 16 to 26 mm for the Graftmaster (Abbott, Abbott Park, Illinois) and the Papyrus stent (Biotronik, Berlin, Germany). Patients with longer aneurysmal segments have been difficult to treat reliably using covered stents. Although multiple overlapping covered stent use has been reported in 2 patients in the literature (3,4), these stents are less trackable compared with conventional stents, and hence the probability of the inability to cross the free-hanging proximal end of the first deployed covered stent with the second covered stents to create the necessary overlap and proper sealing needs to be considered, and the uncertainty may make the interventional operator and the patient reconsider percutaneous options for treatment of longer aneurysmal segments.
We describe a case of a right coronary artery aneurysm with an angiographically estimated length exceeding 30 mm treated percutaneously using covered stents and conventionally available hardware.
• To be able to treat long coronary aneurysms with covered stents.
• To be able to increase the probability of procedural success using contemporary devices and techniques.
History of Presentation
A 25-year-old woman presented to a tertiary care center in Ahmedabad, India, with new-onset retrosternal chest pain. She had no coronary risk factors. The initial 12-lead electrocardiogram showed inferior ST-segment depression and T-wave inversion. Troponin T was elevated at 5.3 ng/ml (normal reference <0.04 ng/ml). She had another episode of chest pain while at rest with dynamic inferior ST-segment depression.
Past Medical History
The patient had no past history of any medical conditions. She did not report any family history of aneurysms or sudden death.
Coronary angiography was performed that showed a fusiform long aneurysm in the mid-right coronary artery (Figure 1). The left main, left anterior descending, and left circumflex arteries as well as their branches were angiographically normal and had normal flow. Besides the coronary tree, the cerebrovascular tree and large vessels were imaged for the presence of aneurysms using computed tomography angiograms of the chest, abdomen, and brain, and no other aneurysms were detected.
In view of the absence of atherosclerotic risk factors, obstructive coronary artery disease, spasm, or other etiologies, coronary embolism from the aneurysm was felt to be the most likely explanation for the acute coronary syndrome presentation, especially in view of the concordance of the ST-segment changes in the inferior electrocardiographic leads and right coronary territory embolism from the right coronary artery aneurysm. A genetic disorder leading to aneurysms in multiple vascular sectors was a possibility; hence, other circulatory beds were scanned, although no aneurysms were identified in the cerebrovascular, aortic, or viscero-peripheral distributions.
After an extensive discussion of several treatment options with the patient including dual antiplatelet therapy and cautious monitoring with follow-up noninvasive imaging versus exclusion of the aneurysm either percutaneously or surgically, the patient elected to proceed with percutaneous coronary intervention for exclusion of the aneurysm.
A 6-F hydrophilic introducer sheath was placed in the right radial artery after standard preparation, and 6-F JR4 guide catheter was used to engage right coronary artery ostium. A 0.014-inch coronary guidewire was placed successfully in the distal right coronary artery after careful maneuvering. A 3.0/38-mm drug-eluting stent was deployed at the proximal to mid-right coronary artery encompassing the aneurysmal segment, with proximal and distal landing zones in the normal reference segments (Figure 2).
After making a metallic foundation bridging the 2 normal segments across the aneurysm, a 3.0/26-mm Papyrus stent was deployed from the distal reference segment projecting part way into the aneurysmal segment inside the previously deployed drug-eluting stent. Another 3.0/18-mm Papyrus stent was deployed with 2 to 3 mm overlap with the previous Papyrus stent in the proximal segment of the aneurysm, projecting into the normal reference segment (Figure 3). The stents were post-dilated with a 3.25/15-mm noncompliant balloon to achieve adequate stent expansion (Figure 4). Optical coherence tomographic imaging was performed using a Dragonfly catheter (Abbott Vascular Inc., Redwood City, California) in a standard fashion (Figure 5), indicating adequate stent expansion and optimal apposition in the nonaneurysmal edges. The electrocardiographic changes resolved and did not recur after the procedure.
Coronary artery aneurysms present a challenge from a procedural and management standpoint, especially in younger patients in whom in view of the lack of clarity of the natural history, the potential risks associated with this disease favor procedure-based exclusion, either percutaneous or surgical.
Percutaneous exclusion of these aneurysms using covered stents offers a very attractive option in view of its acute efficacy as well as procedural simplicity. One of the limitations of percutaneous exclusion of coronary aneurysms is the limited availability of the covered stent lengths. Longer segments such as in this patient pose a particular challenge because 26 mm of covered stent would not successfully exclude the aneurysm.
Although one can try to telescope a covered stent into a previously deployed free-hanging end of another covered stent, this technique has limited reliability, especially in anatomically adverse coronary substrates, and the inability to advance the second covered stent into the first deployed covered stent may lead to ineffective exclusion of the aneurysmal sac and potentially create a nidus for thrombus formation due to persistent stasis and metallic and polytetrafluoroethylene-related hardware burden. Hence, creating a tubular lumen traversing the aneurysmal segment is likely to aid in precise placement of overlapping covered stents and hence improve procedural safety. This may be achieved using our described technique. Using our technique, creating a metallic “bridge” across the aneurysm flanking the segment from normal proximal to distal reference landing zones and then using this metallic foundation to precisely deploy multiple covered stents inside the conventional stent architecture, can reliably exclude the aneurysm segment utilizing the available contemporary hardware. The other benefit of this technique, using a drug-eluting stent as a bridge, is the potential lower restenosis rate at the landing zones. The multilayer metal burden may increase the risk of target vessel failure. Continuing dual antiplatelet therapy for a longer duration may help mitigate the potentially higher risk of thrombotic events.
Our technique allows the interventional operator to offer the patients with long coronary artery aneurysms a safe option with less uncertainty and likely higher procedural success, enhancing the capability of the percutaneous procedure to long coronary aneurysms. The feasibility of this technique through 6-F guide catheters makes it possible to perform these procedures using transradial access, further increasing procedural safety and comfort.
Coronary angiography was repeated at the 6-month follow-up with no angiographic lumen narrowing or hemodynamically significant stenoses (Figure 6). Optical coherence tomography was performed with excellent endothelial coverage of the stent hardware and mild thickening at the overlapping segment of the Papyrus stent, likely caused by dual hardware layer–related signature or mild intimal hyperplasia (Figure 7). The geometry of the lumen was found to be symmetric.
Percutaneous exclusion of coronary artery aneurysms for the prevention of future complications could be offered to patients with longer segments of aneurysms by using overlapping covered stents, improving procedural certainty by deploying a long conventional stent first and using it to create tubular architecture across the aneurysmal segment.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 16, 2019.
- Revision received October 2, 2019.
- Accepted October 9, 2019.
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