Highlights
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Iatrogenic left main coronary artery pseudoaneurysm from in-stent restenosis is extremely rare.
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This is the first report of this specific complication presenting as ST-elevation myocardial infarction.
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A hybrid technique using coils and drug-eluting stent proved successful.
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Optical coherence tomography imaging confirmed complete aneurysm sealing and optimal stent result.
An iatrogenic pseudoaneurysm of the left main coronary artery (LMCA) originating from in-stent restenosis represents an exceedingly rare and life-threatening complication of percutaneous coronary intervention. When such a lesion presents as an ST-elevation myocardial infarction (STEMI), it creates a clinical scenario of extraordinary therapeutic complexity. We report the case of a 78-year-old man with a history of complex multivessel percutaneous coronary intervention who presented with an anteroseptal STEMI. His emergent coronary angiogram identified the culprit lesion as critical in-stent restenosis of a previously stented LMCA trifurcation, which was further complicated by a large pseudoaneurysm within the stent body. Following hemodynamic stabilization with an intra-aortic balloon pump, a novel hybrid percutaneous strategy was undertaken. The intervention involved meticulous high-pressure balloon angioplasty to address the restenosis, followed by the complete exclusion of the pseudoaneurysm using endovascular coil embolization. Finally, coronary perfusion was re-established by implanting a contemporary drug-eluting stent. Postprocedural optical coherence tomography confirmed the successful sealing of the pseudoaneurysm and optimal stent apposition. This case documents a uniquely catastrophic clinical event and appears to be the first documented instance of an iatrogenic LMCA pseudoaneurysm secondary to ISR presenting as a STEMI. Our successful management demonstrates that a hybrid technique integrating coil embolization with modern drug-eluting stent implantation is a viable and effective strategy for confronting this formidable clinical challenge.
Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has become the cornerstone of treating obstructive coronary artery disease. Despite significant technological advancements, iatrogenic complications, though infrequent, remain a major concern. Among the most feared of these is the formation of a coronary artery pseudoaneurysm, a contained vessel rupture confined only by the adventitia or surrounding tissue. The incidence of this complication is low, and its occurrence in the left main coronary artery (LMCA)—the vessel supplying the majority of the left ventricular myocardium—is exceptionally rare, accounting for a mere 1.5% of these events. ,
The pathophysiological substrate for pseudoaneurysm formation often involves deep vessel wall injury from aggressive PCI techniques, a risk that is magnified when treating in-stent restenosis (ISR). The fibrotic and noncompliant nature of restenotic tissue frequently necessitates high-pressure balloon inflations or atherectomy, increasing the likelihood of vessel trauma. While the link between treating ISR and subsequent pseudoaneurysm formation is mechanistically plausible, it is very rarely documented.
While the exact clinical constellation presented in this report appears novel, a few published cases describe scenarios with significant overlap (Table 1) . Al-Lamee et al. reported an LMCA pseudoaneurysm that also arose from the substrate of severe ISR; however, the patient presented with heart failure and was managed with a covered stent. Similarly, Wiemer et al. treated an LMCA pseudoaneurysm presenting as a non–ST-elevation myocardial infarction (NSTEMI) with a covered stent, while Bansal et al. described a case presenting with cardiopulmonary arrest. The closest technical analogue was described by Takeda et al. who employed a hybrid strategy of coils and kissing covered stents for an iatrogenic LMCA pseudoaneurysm; yet, this complication arose from an acute vessel rupture during PCI rather than from treating chronic ISR. Another case, by Mace et al. involved an LMCA pseudoaneurysm that evolved from a spontaneous dissection and was treated with DES alone. These cases highlight the spectrum of complex LMCA complications but also underscore the unique intersection of etiology (ISR), presentation (ST-elevation myocardial infarction [STEMI]), and therapeutic modality (coils plus DES) in our patient.
Table 1
Comparison of etiology, presentation, and treatment of similar cases of LMCA.
| Study | Patient demographics (age/sex) | Etiology of pseudoaneurysm | Clinical presentation | Treatment modality | Key distinctions from present case |
|---|---|---|---|---|---|
| Al-Lamee et al. | 71/M | Severe ISR of ostial LCx stent | New onset heart failure | Single strategy ( Covered stent ) | Presentation as heart failure; treated with a covered stent |
| Wiemer et al. | 55/M | Post LM-LAD-LCx culotte stenting | NSTEMI | Single strategy ( Covered stent ) | Presentation as NSTEMI; treated with a covered stent |
| Bansal et al. | 42/M | LM bifurcation PCI (ZES) | Hemoptysis, cardiac arrest | Single strategy ( covered stent ) | Catastrophic presentation but not STEMI; treated with a covered stent |
| Takeda et al. | 70/M | Iatrogenic rupture during LM bifurcation PCI | Progressive extravasation | Hybrid strategy ( 4 coils + 2 covered kissing stents ) | Etiology was acute rupture, not ISR; treated with coils and covered stents |
| Mace et al. | 36/F | Evolution of LMCA SCAD | Incidental finding | Single strategy ( 2 overlapping DES ) | Etiology was SCAD, not ISR; treated with overlapping DES only |
| Present case | 78/M | Treatment of LMCA ISR | STEMI | Hybrid strategy ( coil embolization + drug-eluting stent ) | Unique combination of ISR etiology, STEMI presentation, and treatment with coils plus a drug-eluting stent |
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