
==== Front
Egypt Heart J
Egypt Heart J
The Egyptian Heart Journal
1110-2608
2090-911X
Springer Berlin Heidelberg Berlin/Heidelberg

39225872
546
10.1186/s43044-024-00546-7
Case Report
Recurrence following percutaneous exclusion of giant coronary pseudoaneurysm: a case report
http://orcid.org/0000-0001-6197-8000
Mukhopadhyay Saibal
http://orcid.org/0000-0002-0621-1509
Yusuf Jamal
http://orcid.org/0009-0000-4207-9966
Gautam Ankur gautam171989@gmail.com

http://orcid.org/0000-0002-7860-8564
Kathuria Sanjeev
http://orcid.org/0000-0002-5583-7743
Batra Vishal
https://ror.org/058fy8f68 grid.413241.1 0000 0004 1767 6533 Department of Cardiology, GB Pant Hospital, Academic Block, First Floor, Room No. 129, 1, Jawaharlal Nehru Marg, 64 Khamba, Raj Ghat, New Delhi, Delhi 110002 India
3 9 2024
3 9 2024
12 2024
76 1182 2 2024
16 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Background

Emergence of coronary giant pseudoaneurysm (PSA) after stent implantation is potentially catastrophic and may end up with life threatening complications if not managed promptly. There is scarcity of data in existing literature with respect to guidelines on the management of coronary PSA following stent implantation. We report the recurrence of coronary PSA following initial percutaneous management of a giant coronary PSA using multiple stent grafts.

Case presentation

A 38-year-old male who underwent primary angioplasty of the right coronary artery (RCA) about a month back, presented with dull aching precordial chest pain for the last 15 days. A repeat coronary angiography revealed giant coronary PSA in proximal to mid RCA. Considering the significantly large size of the coronary PSA with symptoms of impending rupture, the giant coronary PSA was successfully excluded by implanting three sequentially coronary stent grafts. However, after one and a half months, the patient again presented with a similar kind of dull aching chest pain. We found a recurrence of coronary PSA in a segment of the coronary artery distal to the portion excluded by stent grafts. This recurrent coronary PSA was once again successfully excluded by redeploying two more stent grafts with the help of a guide extension catheter.

Conclusions

In this case, vessel wall injury as a result of aggressive post dilatation using an oversized balloon during the index procedure was the contributor to the giant coronary PSA formation. It usually appears early after the index procedure (within 4 weeks). Though the usual strategy used to exclude coronary aneurysm is by using the minimal number of stent grafts (due to the inherent increased risk of restenosis/thrombosis in stent grafts) in post angioplasty traumatic aneurysm it is prudent to exclude the entire damaged artery by placing stent grafts to prevent recurrence in segments with even minimal dilatation on initial evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-024-00546-7.

Keywords

Coronary artery aneurysm
Pseudoaneurysm
Stent grafts
Guide extension catheter
Optical coherence tomography
Percutaneous coronary intervention
issue-copyright-statement© Egyptian Society of Cardiology 2024
==== Body
pmcBackground

Occurrence of coronary artery pseudoaneurysm (PSA) is a rare and under-diagnosed complication following implantation of drug eluting stent (DES). A coronary artery aneurysm is defined as localized dilatation of the coronary artery exceeding 1.5 times of reference vessel diameter and if the diameter exceeds the reference vessel diameter by > 4 times it is referred to as a giant coronary aneurysm [1, 2]. Giant coronary PSAs often present with non-specific symptoms but can lead to fatal complications like rupture, myocardial infarction and sudden death [3, 4]. Hence, timely diagnosis and early intervention are essential to improve the outcome of patients with giant coronary PSA. We report recurrent formation of a coronary PSA following successful exclusion of a giant coronary PSA by three stent grafts necessitating repeat intervention and treatment by additional stent graft.

Case presentation

A 38-year-old hypertensive, smoker and non-diabetic male underwent primary percutaneous coronary intervention (PCI) of the right coronary artery (RCA) about a month back in a peripheral center. He presented with dull aching constant precordial chest pain, fifteen days following the procedure. On presentation, he was afebrile with no abnormality detected on cardiovascular examinations. The 12 lead electrocardiogram (ECG) did not show any fresh changes compared to old ECGs and the cardiac biomarkers (CK-MB and troponins) were also normal. The left ventricular ejection fraction assessed by 2D echocardiography was around 60% without any regional wall motion abnormalities.

Records of angioplasty revealed that the patient had undergone successful primary PCI of RCA. Two sequential Zotarolimus eluting stents Resolute Onyx (Medtronic, CA, USA) of size 3 × 24 mm and 3.5 × 32 mm were deployed at 12 atm pressure from distal to proximal RCA. Post dilatation was done using 3.25 × 12 mm and 4 × 12 mm non- compliant Sprinter balloons (Medtronic, Minneapolis, USA) at high pressure (18 atm pressure) resulting in thrombolysis in myocardial infarction (TIMI)-3 flow.

Check angiogram revealed a giant coronary PSA in the proximal and mid portion of RCA stents (Fig. 1A and B) (videos 1 and 2). Considering the significantly large size of the coronary PSA with symptoms of impending rupture, the decision of urgent percutaneous exclusion using coronary stent grafts was undertaken. Thereafter, three coronary stent grafts [2 Graftmaster (Abbott Vascular, Santa Clara, CA, USA) (2.8 × 16 mm, 3.5 × 16 mm) and PK Papyrus (Biotronik AG, Bülach, Switzerland) 3.5 × 20 mm] were placed sequentially from mid to proximal RCA to exclude the coronary PSA successfully (Fig. 1C and D) (video 3) with TIMI-3 flow in RCA. He was discharged on day 5 of the procedure on medications comprising of dual antiplatelet therapy (aspirin 75 mg once a day and ticagrelor 90 mg twice a day), high intensity statins (rosuvastatin 40 mg/day) and bisoprolol 5 mg/day.Fig. 1 A, B Coronary angiogram of right coronary artery in Left anterior oblique (LAO) and right anterior oblique (RAO) view, respectively, shows giant coronary PSA (arrow denotes). C, D Coronary angiogram shows complete exclusion of giant coronary PSA after implanting stent grafts in LAO and RAO view, respectively

After one and a half months of the procedure, the patient again presented with a similar complaint of dull aching precordial chest pain. A repeat coronary angiogram revealed coronary PSA of 1.2 × 1.2 cm just distal to the previously implanted stent grafts (Fig. 2A) (video 4). In view of constant symptoms, we decided to exclude this aneurysmal segment by placing coronary stent grafts. We also did a pre-procedural optical coherence tomography (OCT) to delineate the coronary PSA and extent of medial damage (Fig. 2B). However, negotiating a stent graft through previously placed stent grafts was difficult. Hence, we delivered a PK Papyrus stent graft (3 × 20 mm) through a 6F Guidezilla™ (Boston Scientific, Marlborough, MA) guide extension catheter (Fig. 2C). Further, after placement of the only available PK Papyrus stent graft distally to exclude the PSA segment, a small segment of the PSA segment remained uncovered proximally and needed exclusion by an additional stent graft. Due to the non-availability of another PK Papyrus stent graft, we planned to exclude the remaining uncovered segment by a Graftmaster stent graft. We needed a 7F guide extension catheter to deliver the stent graft as the higher profile Graftmaster stent cannot be passed through a 6F guide extension catheter. A Graftmaster stent graft (2.8 × 16) mm was delivered through a 7F Guidezilla™ guide extension catheter resulting in the complete exclusion of the coronary PSA. The patient was discharged successfully on day 3 and at six months follow-up, the patient remained asymptomatic.Fig. 2 A Repeat coronary angiogram shows recurrence of coronary PSA distal to the deployed stent grafts (Arrow denotes). B OCT run of RCA shows coronary PSA (arrow denotes). C The black arrow denotes the guide extension catheter through which stent graft (white arrow) was delivered. D Arrow shows mild dilatation of the artery distal to the deployed stent grafts in the initial angiogram

Discussion

Coronary PSA following PCI is rare, with a reported incidence of 0.3–6.0%; and giant coronary PSA is extremely rare with a reported incidence of 0.02% [1]. Giant coronary PSA often involves RCA adjacent to the right atrium, as the adjacent area of the atrium is weak that facilitates the development and expansion of the aneurysm [5].

Three different types of coronary PSA after PCI with stent implantation have been described [1] (Table 1). Type-I coronary PSA exhibits rapid early growth and it manifests within four weeks of the procedure. Oversized balloons or high-pressure balloon inflation causing medial disruption and weakening of the vessel wall leading to coronary PSA formation [6, 7]. Our case was a type-I coronary PSA secondary to post dilatation of the stents with oversized balloons at high pressure. Type-II coronary PSA has a sub-acute to chronic presentation and is usually detected 6 months after the procedure. A polymer, drug or metallic component of stents can induce chronic local hypersensitivity reaction that results in weakening of the arterial wall with subsequent dilatation [8]. The third subtype is mycotic or infectious in etiology (type-III coronary PSA) which presents with fever and systemic manifestations of bacteremia [9].Table 1 Mechanism related to coronary aneurysm formation following DES implantation

Type-I coronary PSA (Mechanical injury of arterial wall)	
 Using oversized balloons/ stents	
 High-pressure balloon/stent inflation	
 Ablative techniques excisional atherectomy, laser angioplasty	
Type-II coronary PSA	
 Polymer related hypersensitivity reaction or vasculitis	
 Incomplete endothelization due to local anti-proliferative drugs	
 Late stent malapposition	
Type-III coronary PSA	
 Stent site infection	
DES drug eluting stent, PSA pseudoaneurysm

Considering the recurrence of the coronary PSA, we did an attentive reassessment of the initial angiogram and found that there was mild dilatation of the artery distal to the deployed stent grafts (Fig. 2D). There was progressive dilatation of this damaged segment leading to recurrence. We suggest that in patients with type-1 coronary PSA, the entire segment of artery with evidence of medial damage should be excluded by placing stent grafts to prevent recurrence rather than targeting the maximally dilated part of the PSA.

In such cases, intravascular imaging should always be undertaken to document the extent of medial damage and its exclusion by placement of stent grafts. In our patient, during the initial procedure which was done on an urgent basis imaging could not be done due to the non-availability of the imaging facility. Secondly, during the re-intervention we faced technical challenges. As stent grafts are less trackable, we needed a 6F guide extension catheter [internal diameter (ID) 1.45 mm] to deliver a PK Papyrus stent graft (crimped profile 1.19 mm) distal to the previously placed stent grafts. As only one PK Papyrus stent graft was available, we realized that to pass a higher profile Graftmaster (a single graft sandwiched between 2 stents) we would require a 7F guide extension catheter (ID of 1.60 mm) which can accommodate a Graft master stent (crimped profile 1.57 mm) (Table 2).Table 2 Size of available stent grafts (crimped profile) and their compatibility with guide extension catheter

ID of guide extension catheter (Guidzilla)	ED of PK Papyrus stent (crimped profile)—1.19 mm	ED of Graft master stent (crimped profile)—1.57 mm	
6F-0.057″ (1.45 mm)	Compatible	Non-compatible	
7F-0.063′ (1.60 mm)	Compatible	Compatible	
ID internal diameter, ED external diameter

In the present case, we realized that even a small dilatation in a vessel which had been damaged initially can later develop into a clinically significant aneurysm. Hence, we decide that intravascular imaging (intravascular ultrasound or OCT) should be done during the initial presentation to delineate the extent of medial damage and the entire segment of the artery with medial damage irrespective of the degree of dilatation should be excluded by the placement of stent grafts to prevent future recurrence.

Conclusions

A development of a giant coronary PSA following implantation of DES is a rare entity but may cause a serious catastrophe if not managed promptly. We recommend total length of the damaged artery (even if non-aneurysmal) to be treated and excluded by stent grafts to prevent future recurrence.

Supplementary Information

Supplementary Video 1. Coronary angiogram in LAO view Shows a giant coronary PSA in the proximal and mid portion of RCA stents.

Supplementary Video 2. Coronary angiogram in lateral view Shows a giant coronary PSA in the proximal and mid portion of RCA stents.

Supplementary Video 3. Coronary angiogram shows complete exclusion of giant coronary PSA after implanting three sequential stent grafts.

Supplementary Video 4. Repeat coronary angiogram shows a recurrence of coronary PSA just distal to the previously implanted stent grafts.

Abbreviations

PSA Pseudoaneurysm

DES Drug eluting stent

PCI Percutaneous coronary intervention

RCA Right coronary artery

ECG Electrocardiogram

TIMI Thrombolysis in myocardial infarction

OCT Optical coherence tomography

ID Internal diameter

Acknowledgements

None.

Author contributions

SM was the primary operator of this procedure. JY and AG drafted and revised the report. The manuscript was further edited by SK and VB. All the authors have read and approved the manuscript.

Funding

There are no sources of funding to declare.

Availability of data and materials

All data generated or analyzed during this study are included in this published article (and its supplementary information files).

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

The authors confirm that written consent for the creation, submission, and publication of this report (and all associated contents) has been obtained from the patient. The patient understand that his name and initial will not be published and due efforts will be made to conceal his identity.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Aoki J Kirtane A Leon MB Dangas G Coronary artery aneurysms after drug-eluting stent implantation J Am Coll Cardiovasc Interv 2008 1 14 21 10.1016/j.jcin.2007.10.004
Aoki J, Kirtane A, Leon MB, Dangas G (2008) Coronary artery aneurysms after drug-eluting stent implantation. J Am Coll Cardiovasc Interv 1:14–2110.1016/j.jcin.2007.10.004
2. Li D Wu Q Sun L Song Y Wang W Pan S Surgical treatment of giant coronary artery aneurysm J Thorac Cardiovasc Surg 2005 130 3 817 821 10.1016/j.jtcvs.2005.04.004 16153934
Li D, Wu Q, Sun L, Song Y, Wang W, Pan S et al (2005) Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg 130(3):817–82116153934 10.1016/j.jtcvs.2005.04.004
3. Ramirez FD Hibbert B Simard T Pourdjabbar A Wilson KR Hibbert R Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases Circulation 2012 126 2248 2256 10.1161/CIRCULATIONAHA.112.101592 23109515
Ramirez FD, Hibbert B, Simard T, Pourdjabbar A, Wilson KR, Hibbert R et al (2012) Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases. Circulation 126:2248–225623109515 10.1161/CIRCULATIONAHA.112.101592
4. Ebina T Ishikawa Y Uchida K Suzuki S Imoto K Okuda J A case of giant coronary artery aneurysm and literature review J Cardiol 2009 53 293 300 10.1016/j.jjcc.2008.07.015 19304136
Ebina T, Ishikawa Y, Uchida K, Suzuki S, Imoto K, Okuda J et al (2009) A case of giant coronary artery aneurysm and literature review. J Cardiol 53:293–30019304136 10.1016/j.jjcc.2008.07.015
5. Syed M Lesch M Coronary artery aneurysm: a review Prog Cardiovasc Dis 1997 40 77 84 10.1016/S0033-0620(97)80024-2 9247557
Syed M, Lesch M (1997) Coronary artery aneurysm: a review. Prog Cardiovasc Dis 40:77–849247557 10.1016/S0033-0620(97)80024-2
6. Gupta RK Sapra R Kaul U Early aneurysm formation after drug-eluting stent implantation: an unusual life-threatening complication J Invasive Cardiol 2006 18 E140 E142 16723749
Gupta RK, Sapra R, Kaul U (2006) Early aneurysm formation after drug-eluting stent implantation: an unusual life-threatening complication. J Invasive Cardiol 18:E140–E14216723749
7. Zhang F Qian JY Ge JB Rapid development of late stent malappositon and coronary aneurysm following implantation of a paclitaxel-eluting coronary stent Chin Med J (Engl) 2007 120 614 616 10.1097/00029330-200704010-00019 17442215
Zhang F, Qian JY, Ge JB (2007) Rapid development of late stent malappositon and coronary aneurysm following implantation of a paclitaxel-eluting coronary stent. Chin Med J (Engl) 120:614–61617442215 10.1097/00029330-200704010-00019
8. Lubell D Gruberg L Hermiller JB Gonschior P Post-stent very proximal left anterior descending coronary artery aneurysm J Invasive Cardiol 2005 17 230 232 15831979
Lubell D, Gruberg L, Hermiller JB, Gonschior P (2005) Post-stent very proximal left anterior descending coronary artery aneurysm. J Invasive Cardiol 17:230–23215831979
9. Liu JC Cziperle DJ Kleinman B Loeb H Coronary abscess: a complication of stenting Catheter Cardiovasc Interv 2003 58 69 71 10.1002/ccd.10395 12508199
Liu JC, Cziperle DJ, Kleinman B, Loeb H (2003) Coronary abscess: a complication of stenting. Catheter Cardiovasc Interv 58:69–7112508199 10.1002/ccd.10395
