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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 11  |  Issue : 2  |  Page : 142-144

A case of stent aneurysm following everolimus eluting stent implantation


1 Department of Cardiology, Institute of Cardio Vascular Sciences, Kolkata, India
2 Director I.C.V.S, R. G. Kar Medical College and Hospital, Kolkata, India
3 Department of Cardiology, R. G. Kar Medical College and Hospital, Kolkata, India
4 Department of Paediatric Medicine, Chittaranjan Seva Sadan, Kolkata, India
5 Department of Medicine, College of Medicine and JNM Hospital, Kalyani, Nadia, West Bengal, India

Date of Web Publication3-Oct-2014

Correspondence Address:
Tanmay Mukhopadhyay
242/3B, APC Road, Nandan Apartment, Flat C - 1, Second Floor, Kolkata - 700 004, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.142128

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  Abstract 

Coronary artery aneurysm commonly occurs secondary to atherosclerosis,but aneurysm formation after stenting is a rare phenomenon specially after drug eluting stent implantation. Drug-eluting stents (DES) elute antiproliferative drugs, can inhibit neointimal growth and may delay healing after vascular injury, and DES implantation may be associated with a risk of coronary artery aneurysm formation. Coronary aneurysms have been reported from 3 days to up to 4 years after DES implantation procedures, with varying clinical presentations. Incidence of coronary artery aneurysms after DES implantation is low within the first 9 months, with a reported incidence of 0.2% to 2.3%, a rate similar to that reported after bare-metal stent (BMS) implantation (0.3% to 3.9%). In our case,the patient is a nondiabetic ,nonhypertensive 68 year old male who underwent coronary angioplasty in the RCA with everolimus eluting stent following acute coronary syndrome.After few weeks the patient came with exertional angina and coronary angiography revealed stent aneurysm formation with new disease proximal to the stent.

Keywords: Drug eluting stent, everolimus, stent aneurysm


How to cite this article:
Mukhopadhyay T, Chatterjee SS, Majumder B, Mandal I, Biswas U. A case of stent aneurysm following everolimus eluting stent implantation. Nig J Cardiol 2014;11:142-4

How to cite this URL:
Mukhopadhyay T, Chatterjee SS, Majumder B, Mandal I, Biswas U. A case of stent aneurysm following everolimus eluting stent implantation. Nig J Cardiol [serial online] 2014 [cited 2020 Apr 5];11:142-4. Available from: http://www.nigjcardiol.org/text.asp?2014/11/2/142/142128


  Introduction Top


Aneurysmal dilation of the coronary arteries was first described by Bougon in 1812. [1] Most commonly, coronary artery aneurysms are secondary to atherosclerosis, [2] but cases have been reported in patients who have vasculitis (Kawasaki syndrome, [3] for example) or tissue disorders (Ehlers-Danlos [4] or Marfan syndrome, [5] for example), and in patients who have undergone interventional procedures. [6],[7]

Drug-eluting stents (DES) elute antiproliferative drugs, and can dramatically inhibit neointimal growth. However, several studies have indicated that DES may delay healing after vascular injury, and DES implantation may be associated with a risk of coronary artery aneurysm formation. [8]

Coronary aneurysms have been reported from 3 days to up to 4 years after DES implantation procedures, with varying clinical presentations. Incidence of coronary artery aneurysms after DES implantation is low within the first 9 months, with a reported incidence of 0.2-2.3%, a rate similar to that reported after bare-metal stent (BMS) implantation (0.3-3.9%) in the DES versus BMS randomized trials. However, the true incidence of coronary aneurysms among patient population is still not known.

Coronary angiography is the gold standard for the diagnosis of coronary aneurysms, which are defined as a luminal dilation 50% larger than that of the adjacent reference segment. [9] However, coronary angiography provides only luminal information and cannot visualize other structures, including the layers of the arterial wall. Discrimination between true aneurysms and pseudoaneurysms, detection of the aneurysm entry site sometimes caused by stent edge dissection or stent edge injury at acute bends during vessel movement, are important to optimally manage aneurysms after coronary intervention.

The clinical course of coronary artery aneurysms after DES implantation is variable. Some aneurysms naturally resolve, but some aneurysms can lead to life-threatening complications. Although, the best treatment for coronary aneurysms after DES is controversial, combination of the aneurysm size, expansion history, pathophysiology, and symptoms are to be used to decide on treatment.

Expanding pseudoaneurysms, infected aneurysms, and large, chronic (and expanding) aneurysms with symptoms should be treated. Further investigation is necessary to determine the pathophysiology, natural history, and best therapies for DES-associated aneurysms. Among all reported cases of stent aneurysm, mostly paclitaxel and sirolimus were the drugs used in DES. There are very limited reports of the stent aneurysm with everolimus eluting stent.


  Case report Top


In our case, the patient is a nondiabetic, nonhypertensive 68-year-old male who underwent coronary angioplasty in the right coronary artery with everolimus eluting stent following acute coronary syndrome [Figure 1]. Everolimus eluting stent was deployed [Figure 2]. Postdilatation was done using noncompliant balloon. End result was good. Other coronary arteries did not reveal obstructive lesion in coronary angiography. Patient was discharged from hospital in stable condition with medications including dual antiplatelet agents. After a week, the patient had fever for which he consulted physician and fever subsided following medications. At 2 weeks later, the patient presented to the cardiology OPD with the complaint of exertional angina, his drug compliance was good, the patient was admitted for evaluation; coronary angiographic evaluation revealed new lesion proximal to the deployed stent and an aneurysm from the stent site [Figure 3].
Figure 1: Lesion in right coronary artery NJC 1

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Figure 2: Following stent deployment NJC 2

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Figure 3: Stent aneurysm with new lesion in the proximal part NJC 3

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  Discussion Top


Exact pathophysiology of stent aneurysm remains unknown. Most widely accepted theory is infective process leading to development of stent aneurysm. Mostly, the presenting symptoms are fever and angina pectoris due to stent occlusion. Scarcity of published case reports suggests that coronary stent infections represent a rather uncommon complication of percutaneous coronary intervention.

Clinically, significant bacteremia related to invasive nonsurgical cardiological procedures found in various studies. The use of DES during coronary interventions has exploded in recent years, because of their dramatic ability to inhibit neointimal proliferation. However, DES may affect the normal healing process of the vessel wall after vascular injury, resulting in delayed endothelization.

However, it has been suggested that local DES infection may result from direct contamination of the device at the time of delivery or from subsequent bacteremia. DES might constitute a potentially predisposing factor by blunting the local inflammatory response of the vessel wall, favoring the maintenance or extension of the infection. The immunosuppressive activity of DES could be implicated. In most cases Staphylococcus aureus infections have been shown. [10] These patients typically present with fever and systemic manifestations, including septicemia, and a clinical picture of fulminant infection with poor prognosis.

After DES implantation, continuous clinical surveillance under prolonged dual antiplatelet therapy might be indicated, further supported by the possibility of spontaneous aneurysm resolution. Patients with larger total vessel areas and larger areas of malapposition have poorer prognosis.

Therefore, the fate of the coronary aneurysm seems to depend on its size, and in this regard, intravascular ultrasound appears to be superior to angiography. In cases of aneurysm thrombosis, aggressive approaches such as balloon overdilation, coiling, covered stents, or further surgical excision might prevent further devastating complications. Regarding infected aneurysms, antibiotic therapy remains the mainstay of treatment, while it remains to be proven if early surgical intervention may result in an improved outcome in these patients. A radio labeled leukocyte scan could be used early to confirm the diagnosis, if conventional imaging fails to identify the source of infection. [11]

 
  References Top

1.Jarcho S. Bougon on coronary aneurysm (1812). Am J Cardiol 1969;24:551-3.  Back to cited text no. 1
    
2.Oliveros RA, Falsetti HL, Carroll RJ, Heinle RA, Ryan GF. Atherosclerotic coronary artery aneurysm. Report of five cases and review of literature. Arch Intern Med 1974;134:1072-6.  Back to cited text no. 2
    
3.Burns JC, Shike H, Gordon JB, Malhotra A, Schoenwetter M, Kawasaki T. Sequelae of Kawasaki disease in adolescents and young adults. J Am Coll Cardiol 1996;28:253-7.  Back to cited text no. 3
    
4.Di Mario C, Zanchetta M, Maiolino P. Coronary aneurysms in a case of Ehlers-Danlos syndrome. Jpn Heart J 1988;29:491-6.  Back to cited text no. 4
    
5.Onoda K, Tanaka K, Yuasa U, Shimono T, Shimpo H, Yada I. Coronary artery aneurysm in a patient with Marfan syndrome. Ann Thorac Surg 2001;72:1374-7.  Back to cited text no. 5
    
6.Bell MR, Garratt KN, Bresnahan JF, Edwards WD, Holmes DR Jr. Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy. J Am Coll Cardiol 1992;20:1474-81.  Back to cited text no. 6
    
7.Sabaté M, Serruys PW, van der Giessen WJ, Ligthart JM, Coen VL, Kay IP, et al. Geometric vascular remodeling after balloon angioplasty and beta-radiation therapy: A three-dimensional intravascular ultrasound study. Circulation 1999;100:1182-8.  Back to cited text no. 7
    
8.Kotani J, Awata M, Nanto S, Uematsu M, Oshima F, Minamiguchi H, et al. Incomplete neointimal coverage of sirolimus-eluting stents: Angioscopic findings. J Am Coll Cardiol 2006;47:2108-11.  Back to cited text no. 8
    
9.Slota PA, Fischman DL, Savage MP, Rake R, Goldberg S. Frequency and outcome of development of coronary artery aneurysm after intracoronary stent placement and angioplasty. STRESS Trial Investigators. Am J Cardiol 1997;79:1104-6.  Back to cited text no. 9
    
10.Singh H, Singh C, Aggarwal N, Dugal JS, Kumar A, Luthra M. Mycotic aneurysm of left anterior descending artery after sirolimus-eluting stent implantation: A case report. Catheter Cardiovasc Interv 2005;65:282-5.  Back to cited text no. 10
    
11.Lim CP, Ho KL, Tan TT, Wong AS, Tan JW, Chua YL, et al. Infected coronary artery pseudoaneurysm after repeated percutaneous coronary intervention. Ann Thorac Surg 2011;91:e17-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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