Abstract
Coronary pseudoaneurysms are rare complications of coronary perforation or dissection that can progress to rupture and cardiac tamponade. There is no optimal standard treatment, and their management is often guided by individual criteria including the risk of rupture, location in the coronary tree, size and flow in it. All of them must be taken into account when deciding the best treatment strategy.
We report a case in which an Amplatzer Vascular Plug II (AVP II) was used successfully to occlude a distal coronary pseudoaneurysm that developed early after rescue angioplasty in a woman with a myocardial infarction due to spontaneous coronary dissection.
1
Case report
A 50-year-old female patient without known cardiovascular risk factors, on strogen replacement therapy, was admitted to a health center with an inferior ST-elevation acute myocardial infarction (STEMI). Tenecteplase was administered 50 minutes after symptom onset. She finally underwent rescue angioplasty 90 minutes after thrombolysis due to persistent chest pain and ST elevation.
Coronary angiography revealed occlusion of the middle-segment circumflex, secondary to occlusive spiral dissection ( Image 1 ). Heparin 100 UI/Kg weight was administered, 600 mg of clopidogrel and 500 mg of aspirin load was given. A hydrophilic guidewire was advanced (PT2, Boston Scientific Corp, USA) and a 2.0 × 10 mm balloon (PANTERA, Biotronik AG, Switzerland) was inflated at the occlusion site with no flow restoration ( Images 2, 3, 4 ). After the implantation of three overlapped bare metal stents, proximal to distal: 3.5 × 15, 3.5 × 20 and 3.0 × 20 mm (PROKINETIC, Biotronik AG, Switzerland), flow was restored in the circumflex artery ( Images 5, 6 ) but an occlusive dissection at a small distal marginal branch was seen by selective microcatheter injection (FINECROSS, Terumo Corporation, USA) ( Images 7, 8 ).
The patient remained hemodynamically stable with the standard of care at the coronary unit, aspirin 100 mg and clopidogrel 75 mg was administered p.o. daily. In the angiographic control performed one week after, the circumflex artery was patent, but a high flow large pseudoaneurysm was seen at the same spot where the dissection was present in the previous procedure ( Image 9 ).
Via right radial artery through a 6.5 french sheath-less guiding catheter (PB – SHEATH LESS, Asahi Intecc Co. Ltd, Japan) the left coronary artery was engaged and a high support wire (GRANDSLAM, Asahi Intecc Co. Ltd, Japan) was passed distally to the pseudoaneurism ( Images 10 and 11 ). To progress the guiding catheter, a monorail 2.0 × 20 mm balloon (SPRINTER, Medtronic Inc, USA) was inflated at the site of the pseudoaneurism, and the guiding catheter was deeply engaged, reaching selectively the marginal branch ( Images 12 and 13 ). Finally, removing the balloon and the guidewire, the AVP II device (4 mm Amplatzer Vascular Plug II, AGA Medical Corp. USA) was inserted and the distal segment of the marginal branch and its pseudoaneurysm were occluded ( Images 14 and 15 ).
