Very Late Development of Coronary Artery Aneurysm with Total Occlusion following Sirolimus-Eluting Stent Implantation

Abstract

).Coronary artery aneurysm (CAA) is defined as a dilation of the coronary artery that exceeds 1.5 times the reference diameter of the adjacent coronary segments which are angiographically normal.1 Meta-analysis by Hakeem et al 2 reported that the incidence of CAA with drug-eluting stent (DES) was 0.6 to 1.9% at a mean follow-up of 9 months when compared with pre-DES era which was 1.4 to 4.9%. Aneurysm formation has been observed from 1 week to 4 years after DES implantation, and up to 9 years after baremetal stent implantation.3 By using intravascular ultrasound (IVUS), Alfonso et al identified that 1.25% of patients developed CAA after DES implantation in the culprit vessel in acute myocardial infarction. 4 Nakagawa reported that CAA was identified in 1.7% of patients by coronary angiography (CAG) mostly 1 year after the implantation of DES. 5 However, the incidence and natural history of CAAs after percutaneous coronary intervention (PCI) are not well known by CAG alone. 6 Aneurysm formation is more commonly a result of traumatic rupture or deep-vessel injury of an artery. We described a case of angiographic CAA formation 3 years after a sirolimus-eluting stent (SES) implantation accompanied by chronic total occlusion of the stent. Case ReportA 41-year-old African American woman with past medical history of hypertension, hyperlipidemia, and diabetes mellitus type 2 presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. The patient underwent CAG in December 2007. The angiogram revealed a 70% ostial left anterior descending (LAD) artery stenosis (►Fig. 1A), and a 10 to 20% proximal stenosis of left circumflex artery (LCx) and a normal right coronary artery. The patient underwent PCI. A SES (Cypher, Miami, FL, 3.5 Â 8 mm, maximal inflating pressure of 11 atm) was successfully deployed (►Fig. 1B) in ostial LAD. After 3 years (December 2010), the patient presented to cardiology clinic with a 6-month history of chronic stable Keywords ► coronary artery aneurysm ► coronary artery bypass ► sirolimus-eluting stent ► percutaneous coronary intervention AbstractA 41-year-old African American woman presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. Elective cardiac catheterization revealed a 70% ostial left anterior descending (LAD) artery stenosis. The patient underwent percutaneous coronary intervention and a sirolimus-eluting stent (Cypher, Miami, FL, 3.5 Â 8 mm) was successfully deployed. Three years after stent implantation, the patient presented with recurrent angina. Repeat coronary angiography revealed a large aneurysm involving the proximal portion of the stent with a total occlusion at the mid to distal portion of the stent with collaterals to LAD from left circumflex artery. The patient underwent coronary artery bypass surgery with left internal mammary artery graft to LAD and ligation of LAD at its origin proximal to the aneurysm.

Sirolimus salınımlı stent implantasyonundan çok uzun süre sonra gelişen koroner arter anevrizması

“…Bunlara ilave olarak, ilaç salınımlı stentler endotelizasyonu geciktirerek anevrizma oluşumuna yol açabilmektedir (5-7). Ayrıca ilaç toksisitesi ve enfeksiyon gelişimi, işlem sonrası rezidüel diseksiyon kalması, oversize balon ve stent kullanımı nedeniyle arter duvarının zedelenmesi, stentin yüksek basınçla yerleştirilmesi gibi mekanik faktörlerin de perkütan koroner girişim sonrası oluşan anevrizma gelişimi ile ilgili olabileceği bildirilmektedir (8,9).…”

“…KAA tedavisinde anevrizmanın büyüklüğü, anevrizma boyutlarındaki büyüme, anevrizma patofizyolojisi ve hastanın semptomlarının göz önünde bulundurulması gerekir. Genişleyen anevrizma, enfekte olmuş anevrizma ve anevrizmanın normal koroner çapının 2 katından geniş olduğu semptomatik hastalarda tedavi önerilmekte; bu hastaların tedavisinde koroner greft stent veya cerrahi yöntemin seçilebileceği bildirilmektedir (5,8,9). Olgumuzda tedavi için önerilen kriterlerin bulunmaması, kontrol amaçlı başvuruda tesadüfen KAA tespit edilmesi nedeniyle anevrizmaya müdahale edilmedi.…”