1

Introduction

Drug-coated balloons (DCBs) were recently added to the arsenal of percutaneous coronary interventions (PCIs). Not only does this device assure immediate and homogenous drug uptake in vessels of various calibers; it also circumvents some of the major limitations of drug-eluting stents (DES) such as the need for prolonged dual antiplatelet therapy and stent thrombosis . The efficacy of DCBs has been proven mainly in the treatment of in-stent restenosis . Reports regarding the use of DCBs in de novo lesions are limited. Such reports have focused mainly on the treatment of small vessel disease or as part of a strategy for the treatment of bifurcation lesions . Although some registries included a more liberal use of DCBs the scarce data to date has led the current ESC guidelines to recommend the use of DCBs mainly for the treatment of in-stent restenosis .

Aneurysm formation after DES implantation is relatively rare, occurring at an incidence of 0.6–1.9%. There is no reported difference in incidence after DES or bare metal stent implantation . Such events may have variable clinical implications ranging from a long uneventful follow-up to rapid progression and need for cardiac surgery . Very little is known and published about the formation of coronary aneurysms following the use of DCBs, especially when treating de novo lesions. While Kleber et al. have previously reported an aneurysm incidence of only 0.8% after the use of DCBs it is important to note that follow up angiography was performed only four months after the index procedure and in just about half of the patients. Aneurysms were found only amongst patients who were treated for de-novo lesions . We hereby report a case of coronary artery aneurysm formation after the treatment of a de-novo lesion.

2

Case report

A 52 year old male with a history of hypertension, hyperlipidemia and active smoking was admitted with non-ST elevation MI. He underwent bypass surgery 6 years prior and since had several additional catheterizations with implantation of stents mainly due to chest pain.

One year before his current hospitalization the patient was hospitalized due to unstable angina. Angiography revealed patent grafts and stents and also a narrowing of the ostium of the second marginal artery which had not been demonstrated before ( Fig. 1 ). It was decided to perform angioplasty to the new narrowing. Since the diameter of the artery was relatively small it was opted to use a DCB. After predilatation a B.Braun Sequent Please 2.5 × 15 mm balloon was used ( Fig. 2 ) achieving good angiographic result with only slight residual stenosis ( Fig. 3 ). The rest of his hospital stay was uneventful, and he was discharged two days later.

Baseline narrowing of the small second marginal artery.

B.Braun Sequent Please 2.5 × 15-mm balloon for 60 seconds.

Final result after balloons.

The patient returned now, one year after the use of the DCB, with angina and a minor elevation of troponin. It was decided to perform another angiography which revealed quite a similar angiographic picture except that a large aneurysm has developed precisely at the site in which the DCB had been previously inflated ( Fig. 4 A, B ). In order to further assess the aneurysm optical frequency domain imaging (Terumo) had been performed showing an aneurysm length of 40 mm and diameter of 3.5 mm ( Fig. 5 ). Since the aneurysm developed in a small vessel and no flow compromise had been demonstrated it was decided to treat the patient with optimal medical therapy.

(A and B): The angiographic appearance of the coronary artery aneurysm.

OFDI showing an aneurysm length of 40 mm and diameter of 3.5 mm.