Abstract
A 68 year old female patient underwent coronary artery bypass surgery (CABG) 1 year previously. At that time she had a giant coronary artery aneurysm (CAA) of the proximal right coronary artery and severe 3 vessel disease including a severe ostial right coronary artery stenosis, severe stenosis of the proximal and mid left anterior descending artery (LAD) and a totally occluded left circumflex artery. She underwent CABG including left internal mammary artery to LAD, aorto-saphenous venous graft (ASVG) to posterior descending artery and ASVG sequential to the first diagonal and obtuse marginal branch. Subsequent computed tomography and invasive angiography demonstrated increasing size of the aneurysm (from 42 by 37 mm to 50 by 42 mm) which was now fed retrograde via the graft to the posterior descending artery in addition to being fed antegrade by the native vessel through a high grade stenosis. Percutaneous covered stent insertion was planned. The aneurysm was traversed with a guide wire, but passage of Viabahn covered stents was difficult due to the 8 Fr guide catheter and the bulky and rigid structure of the Viabahn stent. Using a distal anchoring technique and dual guide catheters, successful passage of two Viabahn stents (two of 5 by 50 mm) was accomplished. The technique utilized is described.
1
Introduction
Coronary artery aneurysms (CAA) are found in up to approximately 5% of patients undergoing coronary artery angiography and often are reported to be combined with significant atherosclerotic coronary artery disease . Surgery is usually considered as first line treatment for symptomatic patients, however polytetrafluoroethylene (PTFE) covered stent implantation for aneurysm exclusion is another option. A Viabahn covered stent, (W. L. Gore & Associates., Flagstaff, AZ, USA) which was originally developed for treating peripheral arterial disease, may be used for treating CAA. However, use for coronaries can be difficult because of the relatively bulky size and rigidity. We report successful aneurysm exclusion using this device in a giant right coronary artery (RCA) aneurysm which previously received a distal coronary artery bypass graft.
2
Case
A 68 year old female with a history of hypertension, angina and stroke presented with severe chest pain. She was previously found to have a giant CAA in the setting of multi-vessel coronary artery disease ( Fig. 1 A and B ) including severe ostial RCA stenosis, severe proximal and mid left anterior descending artery (LAD) stenosis and a totally occluded left circumflex artery. She underwent coronary artery bypass surgery (CABG) including a left internal mammary artery to the LAD, aorto-saphenous venous graft (ASVG) to the posterior descending artery (PDA) and ASVG sequential to the first diagonal and obtuse marginal branch. However, the aneurysm was not addressed at that time. One year later, although she did not complaint of any discomfort, routine computed tomographic (CT) angiography demonstrated increased size of the aneurysm increasing from 42 by 37 mm to 50 by 42 mm in diameter and half of the aneurysm was filled with thrombus ( Fig. 1 C). However, 2 months after the CT angiography, she was hospitalized with severe chest pain and urgent coronary angiography was performed. Although, all of the grafts were patent ( Fig. 1 D, E), bidirectional contrast angiography using dual catheters from the ASVG to PDA and in the native RCA showed that the aneurysm was much larger than 14 months before and contrast filled about half of it ( Fig. 1 F, arrow heads). Although the native RCA had severe stenosis in the ostium, the aneurysm had enlarged and was now fed without intervening stenosis retrograde via the saphenous graft to the PDA. Although treatment of the aneurysm was urgently required to prevent rupture of the coronary artery, because of a recent stroke and the prior CABG she was felt to be at high risk for surgery and a percutaneous approach was utilized.
Selection of a covered stent to exclude the aneurysm required taking into account several considerations. The aneurysm involved a long segment of the RCA from the proximal portion to the mid RCA and the size of the distal reference vessel was measured at 4.7 mm. In addition, the ostium of the RCA was short, which might compromise complete sealing, and there was critical ostial stenosis. Selection of an appropriate size and type of stent graft was critical to complete sealing of aneurysm. An alternative, the Graftmaster stent is only available in lengths up to 26 mm, while the Viabahn is available in 50 and 100 mm length making it more likely to cover the entire aneurysm. The Graftmaster is a balloon expandable stent, while the Viabahn covered stent is a self-expanding stent which might be preferable to prevent endoleaks and to seal in the short proximal landing zone. Thus, we decided to initially utilize the 5 mm diameter Viabahn stent for covering CAA.
After bilateral sheaths were inserted via both common femoral arteries, an 8 Fr Judkin right guiding catheter (Cordis, Miami Lakes, FL, USA) was engaged into the ostium of the RCA. First, progressive balloon dilation was performed with balloons increasing from 2.75 mm to 4.0 mm to accommodate entry of the bulky device (2.75 by 15 mm and 4.0 by 15 mm, noncompliant Euphora balloon, Medtronic Parkway, Minneapolis, MN, USA; Fig. 2 A ). Passage of the 5 by 100 mm of Viabahn covered stent was attempted, but failed to advance to the landing site distal to the aneurysm in the mid RCA. An 8 Fr AL1 guiding catheter system (Cordis, Miami Lakes, FL, USA) was utilized for better support, but was not successful due to rigidity of the covered stent, and the angulation of the AL1 guide catheter compared with relatively straight guides such as the JR4. A distal balloon anchoring technique (or a coaxial balloon anchoring technique) was then utilized for delivery. Dual guides were utilized to perform this technique. One guide was utilized to pass a balloon distally and anchor the guidewire, and the other guide was utilized for passage of the covered stent over the anchored guidewire. A 0.014″ BMW guidewire (Abbott, Abbott Park, IL, USA) was exchanged for a 0.018″ Steelcore guidewire (Abbott, Abbott Park, IL, USA) within the Viabahn delivery catheter from the JR guiding catheter. A 0.014″ BMW guidewire was utilized to pass a 4 mm by 15 mm Euphora balloon from AL1 guiding catheter (Cordis, Miami Lakes, FL, USA) beyond the aneurysm into the mid RCA anchoring the guidewire. Because the distal RCA was perfused by the graft, it was felt to be safe to inflate the balloon in the RCA proximal to the graft insertion site, but distal to the aneurysm anchoring the guidewire. While this 4 by 15 mm balloon trapped the 0.018″ guidewire in the mid RCA ( Fig. 2 B), the Viabahn covered stent was able to be advanced extending distal to the aneurysm in the mid RCA. Because there was persistent proximal leakage after first device deployment ( Fig. 2 C), an additional Viabahn stent (5 × 50 mm) coverage was performed at the proximal site of the RCA using the same technique ( Fig. 2 D). Finally, prolonged balloon inflation using a peripheral balloon (5 by 20 mm of SAVVY balloon, Cordis, Miami Lakes, FL, USA) was performed as a final step. Complete aneurysm closure was achieved ( Fig. 2 E) and she was discharged with no further chest pain. Angiography, 1 month after the graft insertion, demonstrated a completely sealed aneurysm with good distal flow through the covered stents ( Fig. 2 F).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
