A Giant Coronary Artery Aneurysm Treated With Multiple Overlapping Covered Stents

Alberto F. Cereda, MD

Gianluca Tiberti, MD

Isidoro G. Pera, MD

Edoardo Cantù, MD

Luca A. Ferri, MD

Stefano Savonitto, MD

Luigi Piatti, MD

A 62-year-old man with known coronary artery ectasias was referred to our center in 2001 for ischemic symptoms and mild inferior hypokinesis on echocardiography. Coronary angiography showed diffused coronary artery ectasias with an aneurysmatic appearance of the proximal and mid left circumflex coronary artery without stenotic lesions ( Fig. 3.1 A); a conservative medical approach with aspirin and warfarin was advised. The patient did well with medical therapy thereafter until December 2016, when he was admitted with an inferolateral ST-segment elevation myocardial infarction. Emergency angiography showed the evolution of the mid left circumflex coronary artery lesion into a giant aneurysm with distal thrombotic embolization causing occlusion of the vessel ( Fig. 3.1 B–C, Online Video 3.1 ). Because of the large amount of thrombus, rheolytic coronary mechanical thrombectomy was chosen to remove the occluding clot, with ST-segment resolution ( Fig. 3.1 D–E). One week later, despite triple therapy with aspirin, clopidogrel, and warfarin, recurrent coronary thrombosis occurred, and balloon angioplasty was needed to bridge the patient to the next definitive coronary intervention. The procedure was performed via right radial access, using a 6F extra backup 3.5 catheter. An intravascular ultrasound preevaluation of the distal and proximal landing zones of the giant aneurysm was undertaken, and 4 PK Papyrus stents (Biotronik, Berlin, Germany) were implanted in sequence from the distal to the proximal edge, with 4 to 5 mm of overlap ( Fig. 3.1 F1–F2, G1–G2). The proximal and distal landing zones were postdilated with noncompliant balloons with good angiographic results ( Fig. 3.1 H, Online Video 3.2 ). Intravascular ultrasound grayscale and ChromaFlo (Philips, Volcano, San Diego, California) imaging (Online Video 3.3 ) highlighted the successful apposition of the covered stents and the complete sealing of the aneurysm, also visible on echocardiography ( Fig. 3.1 I, Online Video 3.4 ). At 4 months, the patient is doing well with aspirin and clopidogrel therapy. We succeeded in sealing a giant coronary artery aneurysm, with good angiographic and clinical outcomes, by means of a novel transradial intravascular ultrasound–guided percutaneous technique.

Stove Pipe Technique.

(A) Diffused coronary artery ectasia, more significant in the proximal left circumflex coronary artery (15 × 30 mm) 3 years before the acute coronary syndrome. (B) Giant left coronary artery aneurysm visible on echocardiography in the intensive care unit after clinical stabilization of the patient’s condition with mild left ventricular function reduction (four-chamber view); the giant aneurysm encircled in red . (C) Attempted wiring of the thrombotic occluded left circumflex coronary artery with contrast opacification of the aneurysm.

(D) Distal flow after rheolytic thrombectomy. Note the flow vortex inside the aneurysm (Online Video 3.1 ). (E) Angiography of the giant aneurysm (30 × 50 mm) before covered stenting. (F1) Apposition of the distal PK Papyrus stent (Biotronik, Berlin, Germany) (4.0 × 26 mm). (F2) Apposition in overlapping of the second Papyrus stent (4.0 × 26 mm). (G1) Apposition of the third Papyrus stent (4.5 × 26 mm) overlapping the second stent. (G2) Apposition of the last proximal Papyrus stent (4.0 × 26 mm) and complete sealing of the aneurysm. (H) Final angiographic result. Distal staining of contrast is due to the previous injection before sealing off the aneurysm. Intravascular ultrasonography and ChromaFlo confirmed the results (see Online Video 3.2 ). (I) Image of the covered stents on echocardiography (four-chamber view). The red arrow indicates the covered stent (see Online Videos 3.3 and3.4 ).

Endovascular Coil Embolization of Behçet Disease–Related Giant Aneurysm of the Right Coronary Artery After Failure of Surgical Suture

Patrick T. Siegrist, MD

Satoru Sumitsuji, MD

Keigo Osuga, MD, PhD

Taichi Sakaguchi, MD, PhD

Kouichi Tachibana, MD, PhD

Shinsuke Nanto, MD, PhD

A 69-year-old man with Behçet disease was referred for treatment of a rapidly growing giant aneurysm (38 × 31 mm) of the right coronary artery (RCA), as detected by computed tomography ( Fig. 3.2 A). The patient initially underwent surgery for single coronary artery bypass grafting and RCA ligature. However, because of a heavily calcified vessel wall ( Fig. 3.2 B), probably related to chronic inflammation, the RCA remained patent ( Fig. 3.2 C). Consequently, percutaneous placement of a covered stent graft (CSG) followed by coil embolization (CE) was planned to seal the aneurysm orifice and avoid occlusion of the arterial bypass graft. Considering the orifice length of 32 mm, a long bare-metal stent (BMS) was implanted first to prevent migration of the CSG (our maximal length for CSG is 19 mm). However, the following CSG delivery failed owing to friction in a mild, but calcified, stenosis ( Fig. 3.2 C) and resistance at the proximal edge of the previously implanted BMS. Ultimately, CE within the BMS was performed. The final angiogram showed only mild leakage through the coil and stent struts ( Fig. 3.2 D). Alternative percutaneous strategies involve additional stenting of the proximal stenosis to facilitate CSG placement or multiple-layer BMS along with CE to further enhance sealing of the aneurysm ostium. However, the remaining mild leakage is expected to be self-limiting as a result of thrombus formation.

Endovascular Coiling of Behçet Disease–Related Giant Coronary Aneurysm After Successful Bypass Grafting But Failure of Ligature.

(A) Computed tomography showing a giant aneurysm of the right coronary artery ( RCA ) ( arrowheads ). (B) Intravascular ultrasound (IVUS) shows a heavily calcified vessel wall ( arrows ), rendering proximal and distal surgical sutures inefficient. (C) On follow-up angiography, remaining flow into the aneurysm ( black arrow ), level of previous IVUS image ( dashed arrow ), and a mild, but calcified, stenosis ( white arrow ) are shown. (D) The final angiogram shows only mild leakage through the coil and stent struts ( arrow ). Ao , aorta.

Because data on coronary involvement of Behçet disease are scarce, treatment of coronary aneurysm is controversial. Reports of rupture and thromboembolization-related myocardial infarction suggest prophylactic invasive treatment. Conversely, vascular complications after interventional treatment have been reported. Thus invasive treatment should be considered in case of aneurysm growth, massive size, and recurrent ischemia. For conservative treatment, close monitoring and suppression of underlying vasculitis should be warranted. Additionally, antiplatelet or anticoagulant therapy has been suggested to prevent thromboembolic complications.

Occlusion of a Large Expanding Saphenous Vein Bypass Graft Aneurysm With Percutaneously Injected Ethylene–Vinyl Alcohol Copolymer

Brian Sonnenberg, MD

Jennifer Rutledge, MD

Robert C. Welsh, MD

A 63-year-old man with prior coronary artery bypass graft surgery (9 years earlier) had an incidental diagnosis of a saphenous vein graft (SVG) aneurysm during investigation of an abdominal aortic aneurysm. Computed tomographic scan showed expansion of the SVG aneurysm from 2.3 to 4.5 cm maximal diameter over 2 years ( Fig. 3.3 A). The patient had multiple comorbidities, including peripheral vascular disease, renal failure with a failed prior renal transplant, a hereditary C4 deficiency, and lupus-like syndrome, and was not considered a candidate for repeat open heart surgery. Given the uncertain rupture risk of the expanding SVG aneurysm, he was taken to the cardiac catheterization laboratory for planned coil occlusion. At time of angiography the anatomy was considered incompatible with standard coil occlusion, owing to expansion of the aneurysm with gentle contrast injections and the extensive size ( Fig. 3.3 B–C). Subsequently, a 7F guide catheter was used to engage the SVG with a Marathon microcatheter (EV3 Neurovascular, Irvine, California) advanced over a guidewire into the aneurysm neck. Percutaneously injected ethylene–vinyl alcohol copolymer was used to seal the ostium of the graft aneurysm with successful occlusion of the aneurysm and no residual flow into the aneurysm; a tiny residual tag of the copolymer was left protruding into the ascending aorta ( Fig. 3.3 D). On transesophageal echocardiography 5 weeks later, the ostial vein graft plug was seen, and the patient remains clinically stable. This is the first reported case of percutaneous injection of ethylene–vinyl alcohol copolymer in this situation.

Percutaneous Occlusion of a Saphenous Vein Graft Aneurysm With Ethylene Vinyl Alcohol Copolymer.

(A) An expanding saphenous vein graft aneurysm was discovered in a patient with multiple comorbidities. Percutaneous coil occlusion was planned, given the uncertain rupture risk and high risk of reoperation, but this was not possible because of expansion of the aneurysm with contrast injections and the extensive size (B and C). Subsequently, a guide catheter with a Marathon microcatheter (EV3 Neurovascular, Irvine, California) was advanced into the aneurysm neck. Percutaneously injected ethylene–vinyl alcohol copolymer was used to seal the ostium of the graft aneurysm with successful occlusion and no residual flow into the aneurysm (D).

Overlapping Stent Intervention Treatment of a Giant Right Coronary Artery Pseudoaneurysm

Hai-Long Dai, MD, PhD

Xue-Feng Guang, MD

Li-Hong Jiang, MD, PhD

Qiang Xue, MD

Wei-Hua Zhang, MD

A 69-year-old woman was seen with chest heaviness. She had no remarkable medical history and no history of Kawasaki disease or other inflammatory disease. Echocardiography showed a large paracardiac mass in the lateral free wall of the right atrium. Dual-source 64-slice cardiac computed tomography angiography showed a giant right coronary artery (RCA) pseudoaneurysm (4.4 × 4.5 cm) ( Fig. 3.4 A). Coronary angiography revealed a large pseudoaneurysm in the RCA with 90% stenosis ( Fig. 3.5 A, Online Video 3.5 ).

Dual-Source 64-Slice Cardiac Computed Tomography Angiography.

(A) A giant right coronary artery pseudoaneurysm ( red arrows ) containing contrast ( yellow arrows ). The vessel distal to the pseudoaneurysm shows impaired contrast filling. (B) Nine months after placement of three overlapping stents, total exclusion of the pseudoaneurysm is accomplished and normal distal contrast filling is obtained. RCA, right coronary artery.

Coronary Angiography.

(A) A large pseudoaneurysm in the right coronary artery with 90% stenosis (Online Video 3.5 ). (B) Three overlapping stents were placed, after which only small leaks remained, with an aneurysmal flow reduction (Online Video 3.6 ). (C) One month after the procedure, the pseudoaneurysm was successfully occluded (Online Video 3.7 ).

This coronary pseudoaneurysm may have been spontaneous. Treatment options included resection with bypass grafting, coil embolization, and covered stents. However, aneurysms with collateral branches cannot be treated with covered stents, delayed endothelialization, or thrombosis after covered stent implantation. ^, Some authors reported that treatment of carotid pseudoaneurysms using overlapping stents produced good results.

We decided to perform a percutaneous coronary intervention. After balloon dilation of the stenotic lesion of the RCA, a percutaneous procedure using 3 overlapping stents (Lepu drug-eluting stents, 4.0 × 36 mm, 4.0 × 24 mm, and 4.0 × 18 mm, Lepu Medical, Beijing, China) was performed (The jet of contrast decreased somewhat after the first stent was implanted. A second stent was implanted with reduction in the leak, and we then inserted a third stent.). Although small leaks remained, an overlapping stent intervention induced a slow-velocity flow field in the pseudoaneurysmal sac ( Fig. 3.5 B, Online Video 3.6 ). After the procedure, the patient took aspirin and clopidogrel. One month after the procedure, the patient reported no discomfort. The coronary angiogram revealed that the pseudoaneurysm was completely sealed off, and the branch of the RCA was not affected ( Figure 3.5 C, Online Video 3.7 ). At 9 month follow-up, the patient was symptom free. Cardiac computed tomography angiography demonstrated stent patency and complete coverage of the neck with total exclusion of the pseudoaneurysm ( Fig. 3.4 B). The patient remains asymptomatic at 20-month clinical follow-up.

To the best of our knowledge, this is the first reported percutaneous treatment of a coronary pseudoaneurysm with multiple overlapping stents.

Percutaneous Closure of a Saphenous Vein Graft Aneurysm Causing Left Internal Mammary Artery Compression and Left Ventricular Systolic Dysfunction

Razi Khan, MD

Nirmal Kakani, MD

Pantelis Diamantouros, MD

A 58-year-old man was admitted for aortobifemoral bypass with a diagnosis of bilateral iliac occlusions. He had coronary artery bypass graft surgery 15 years earlier, which included left internal mammary artery (LIMA) grafting to the left anterior descending artery and saphenous vein grafting (SVG) to the second obtuse marginal artery. Preoperative chest x-ray films showed a potential mediastinal mass. Assessment with computed tomography demonstrated a patent 5.1 cm (sagittal) × 7.6 cm (anteroposterior) × 6.3 cm (transverse) SVG aneurysm, with associated compression of the LIMA graft ( Fig. 3.6 A–B).

Assessment of Saphenous Vein Graft Aneurysm Before and After Percutaneous Closure.

(A) Computed tomography (CT) (three-dimensional reconstruction) showing luminal flow in the saphenous vein graft (SVG) aneurysm (the thrombosed portion of the aneurysm is not visualized). (B) CT (three-dimensional reconstruction) showing the SVG aneurysm with compression of the left internal mammary artery (LIMA). Angiographic imaging showing a patent SVG aneurysm (C) and attenuation of contrast through the LIMA graft distal to aneurysmal point of contact (D). (E) CT (two-dimensional) and angiographic (inset) imaging of successful implantation of the Amplatzer vascular plug I (AGA Medical, Golden Valley, Minnesota) ( black arrow ). (F) Angiographic imaging showing restoration of dense contrast passage through the LIMA (see Online Videos 3.8 and3.9 ).

Angiography confirmed a patent SVG aneurysm ( Fig. 3.6 C) with reduced contrast density within the LIMA distal to its aneurysmal contact point ( Fig. 3.6 D), suggesting diminished blood flow through the graft. Left ventriculography showed severe anterior wall hypokinesis (Online Video 3.8 ). Because of its size and associated compression of the LIMA, aneurysmal closure using a percutaneous Amplatzer vascular plug (AGA Medical, Golden Valley, Minnesota) was decided. Risk of LIMA injury with surgical reentry was considered high given its proximity to the sternum.

Given the patient’s bilateral iliac occlusions, vascular access was obtained via the left brachial artery. The SVG graft was engaged using a 6F VL 3.5 guide catheter (Boston Scientific, Natick, Massachusetts) manipulated to the aneurysm neck. The SVG diameter at the site of intended device implantation was 10 mm based on computed tomography/fluoroscopic imaging. A 12-mm Amplatzer vascular plug I was then introduced successfully proximal to the aneurysm. Fluoroscopic and computed tomography imaging confirmed appropriate occluder positioning ( Fig. 3.6 E) with minimal contrast flowing through the device.

Two months after the procedure, angiography demonstrated complete aneurysmal thrombosis, with no flow distal to the vascular plug. Additionally, dense contrast passage was visualized through the LIMA graft with marked improvement of left ventricular function and anterior wall motion ( Fig. 3.1 F, Online Video 3.9 ).

SVG aneurysms are rare complications of coronary artery bypass graft surgery. The natural history of these aneurysms is not well known; however, complications include thrombus embolization, rupture, and erosion into neighboring structures. To our knowledge, this is the first case of SVG aneurysm–associated LIMA compression with resultant left ventricular dysfunction. Although treatment has traditionally involved surgical ligation or excision, percutaneous closure is being increasingly performed, particularly in high-risk surgical patients, such as the patient described in our case. ^,

Percutaneous Closure of Giant Saphenous Vein Graft Aneurysm

Amish C. Sura, MD

John S. Douglas, MD

A 78-year-old man was referred to our institution for treatment of an unusual expanding aneurysm. He had earlier coronary artery bypass surgery in 1999. Subsequently, exertional dyspnea developed, and chest x-ray films showed a right chest mass that was increasing in size. Multislice computed tomography revealed a partially thrombosed 16.5 × 6.5 cm aneurysm arising from the site of the saphenous vein conduit to the right coronary artery and extending in the distribution of this graft, suggesting a true saphenous vein graft aneurysm ( Fig. 3.7 A–B). This aneurysm impinged on the diaphragm, compressed the liver inferiorly, and did not communicate with the distal right coronary artery.

Multislice Computed Tomography.

(A) Shallow left anterior oblique view with multislice computed tomography showing a large aneurysm filled with thrombus with a smaller patent cavity that communicates with the aorta. (B) Image reconstruction showing the relationship of the aneurysm cavity to the aorta. RCA, right coronary artery.

Closure was recommended because of the expanding aneurysm and potential for rupture. A surgical approach was judged possible but required repeat sternotomy and use of cardiopulmonary bypass. Percutaneous closure was judged to be feasible and much less invasive and was elected by the patient.

From a femoral approach, a 7F JR4 guide catheter (Medtronic, Minneapolis, Minnesota) was used to engage the neck of the aneurysm. Angiography was performed ( Fig. 3.8 A) and a 5 × 20 mm balloon was used to “size” the neck at approximately 3 mm in diameter ( Fig. 3.8 B). A stiff guidewire was introduced ( Fig. 3.8 C) over which a 9F Amplatzer delivery sheath was cannulated into the neck of the aneurysm. A 4-mm Amplatzer Septal occluder device (AGA Medical, Golden Valley, Minnesota) was implanted ( Fig. 3.8 D), occluding the aneurysm neck. Aortic angiography and transesophageal echocardiography confirmed the absence of flow into or out of the aneurismal cavity ( Fig. 3.8 E).

Angiography and Closure of Aneurysm in Shallow Left Anterior Oblique View.

(A) Angiogram of aneurysm cavity. (B) Use of coronary balloon to “size” the neck of aneurysm. (C) Stiff wire with formed J and Amplatzer delivery sheath (AGA Medical, Golden Valley, Minnesota). (D) Device deployment. (E) The aortogram after implantation shows absent flow into the aneurysm.

The patient was discharged the next day taking aspirin and clopidogrel (75 mg). At 3 months after the procedure, the patient was asymptomatic and fully active.

Aortocoronary saphenous vein graft aneurysms are a rare complication of coronary artery bypass graft surgery. The incidence is unknown but may be increasing with increasing use of advanced imaging techniques. They often present as a mediastinal mass. Symptoms can be nonspecific and include dyspnea, chest discomfort, and hemoptysis. Aneurysm rupture is associated with a high mortality rate. Such lesions are usually treated surgically, although secondary thrombosis owing to coil implantation has been described. ^,

Percutaneous Luminal Reconstruction of Giant Saphenous Vein Graft Aneurysm

Tiffany Patterson, MBBS BSs

Ian Webb, MD

Simon R. Redwood, MD

A 77-year-old woman had a large contrast-enhancing paracardiac mass localized to the right atrium ( Fig. 3.9 A–B) on screening computed tomography after colonic carcinoma surgery. She had a history of coronary artery bypass grafting with left internal mammary artery to left anterior descending and saphenous vein grafts (SVG) to the obtuse marginal and right coronary artery (RCA) vessels after a myocardial infarction 20 years previously, which was followed by symptom-driven angioplasty to the ostial RCA-SVG.

Percutaneous Reconstruction of Giant Saphenous Vein Graft Aneurysm: Before, During, and After Images.

Contrast-enhanced mediastinal computed tomography of the (A) sagittal and (B) axial planes shows the course of right coronary artery–saphenous vein graft (RCA-SVG) ( red arrow ) and a paracardiac mass ( yellow arrow ) through which it passes. (C) The lumen of the RCA-SVG aneurysm filling with contrast (see Online Video 3.10 ). (D) Luminal reconstruction with covered stents. (E) Deep intubation of the guide catheter to implant the final stent and (F) final result (see Online Video 3.11 ).

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