Conservative Approach for Perforation and Early Pseudoaneurysm of Left Anterior Descending Artery during Overlapped Stenting

From the Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran, and the *Department of Epidemiology, University Medical Center Groningen, Groningen, the Netherlands. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 5, 2008, provisional acceptance given January 13, 2009, and final version accepted February 9. 2009. Address for correspondence: Abbas Soleimani, MD, North Kargar Street, Tehran Heart Center, Postal code 1411713138, Tehran, Iran.,Tehran Heart Center, Tehran University of Medical Sciences E-mails: soleimania@yahoo.com; aliiabbasi@yahoo.com; a.abbasi@epi.umcg.nl

_______________________________________________ ABSTRACT: Coronary artery perforation rarely occurs during or following percutaneous coronary intervention. Its consequences may range from minimal dye staining to tamponade and abrupt hemodynamic collapse. Coronary perforation during angioplasty can evolve into pseudoaneurysm. We report a case in which a vessel perforation and pseudoaneurysm were formed in the mid-portion of the left anterior descending artery during overlapped stenting. The perforation was sealed by inflating the angioplasty balloon. The patient was followed by angiography and intravascular ultrasound. After 1-week observation, the pseudoaneurysm was completely resolved.

_________________________________________________

J INVASIVE CARDIOL 2009;21:E81–E83 Rupture of coronary arteries is a rare complication of percutaneous coronary intervention (PCI). Previous reports cite an incidence varying between 0.1 and 3.0%, depending on the interventional method used.^1–3 It can cause a wide spectrum of conditions, from a benign hematoma of a sealed vessel, to life-threatening bleeding with abrupt hemodynamic collapse. Rarely, a pseudoaneurysm may develop.4 The interventionist faces a challenge in terms of deciding on an appropriate therapeutic approach, especially if a perforation occurs in a major coronary artery. After drug-eluting stents (DES) implantation, aneurysm formation in coronary arteries can occur in 0.2–2.3% of cases.⁵ It can also be a complication of saphenous vein grafts in coronary artery bypass grafting (CABG). Furthermore, it can be a potentially serious condition with a risk of rupture and many other consequences, not the least of which is sudden death. As a result, close observation and management of this condition are essential. We report on a young male who underwent PCI and developed perforation and pseudoaneurysm of the left anterior descending (LAD) artery due to overlapped DES. Case Report. A 36-year-old male with typical chest pain and diaphoresis was admitted with acute coronary syndrome in our center (in July 2008). Not only did he have a cigarette smoking history (21 packs/year) and dyslipidemia, but he also had smoked opium for 13 years. The physical examination was unremarkable. Electrocardiography (ECG) revealed a left posterior hemi-block and T inversion in leads I, avL and V1–V6. Transthoracic echocardiography (TTE) showed septal hypokinesia with a 45% global ejection fraction. Coronary angiography revealed that he had two-vessel disease, a 90% diffuse stenosis in the LAD and 60% stenosis in the left circumflex artery. Based on the American College of Cardiology/American Heart Association Task Force Classification,6 the LAD lesion was Grade C and the reference vessel diameter was 2.9 mm. We decided to perform PCI on the culprit lesion in the LAD. The patient received acetylsalicylic acid (ASA) 325 mg and clopidogrel 600 mg the day before PCI as premedication. After inserting a 6 Fr guiding catheter, 7,500 Units of unfractionated heparin were administered. Predilatation with a 2 mm x 20 mm Maverick® balloon (Boston Scientific Corp., Natick, Massachusetts) at 8 atm inflation pressure was then performed. Subsequently, 2 overlapping Cypher™ Select stents (Cordis Corp., Miami Lakes, Florida) were deployed. The distal stent was 2.5 mm × 28 mm and the proximal stent was 3 mm × 28 mm; they were deployed at 16 atm pressure. Postdilatation was performed using a 2.75 mm × 20 mm Quantum balloon (Boston Scientific) because of the tightness and residual stenosis. After increasing the pressure to 30 atm, the balloon ruptured, leading to a perforation in the vessel wall (Figure 1). Heparin was immediately partially neutralized by protamine sulfate (20 mg), and a 3 mm × 15 mm Maverick balloon was inserted to maintain a prolonged inflation of 4 atm pressure at the site of the perforation for about 10 minutes. The perforation was sealed, and because of some thrombus formation, two inflations at 14 atm and 8 atm were performed in the proximal and distal parts of the stents, respectively. At the end of the procedure, no leakage of the dye or filling defect was detected. Also, TTE confirmed no pericardial effusion. The patient was transferred to the post-angioplasty intensive care unit for close observation. Because of the risk of thrombus formation, heparin (7 u/kg/hr, maximum dose of 500 u/hr) was administered for 21 hours. Routine medical therapy after PCI (i.e., ASA, clopidogrel, propranolol and atorvastatin) was given to the patient. The next day, coronary angiography and intravascular ultrasound (IVUS) were performed. A pseudoaneurysm without any leakage of dye to the pericardium was observed (Figure 2). At IVUS, the stent apposition was acceptable and no dissection was seen in the other segments. The patient remained under close observation on medical therapy for 7 days. He had neither significant clinical findings nor ECG changes. There was no pericardial effusion in repeat TTE during the hospital stay. Also, his cardiac enzymes were within the normal range after PCI. At the third angiography (7 days post PCI), the pseudoaneurysm had completely disappeared (Figure 3). The patient was discharged on a medical regimen 8 days post PCI. He received 75 mg of clopidogrel twice daily for 1 month, which was then changed to 75 mg per day. At 6-month follow up, the patient was symptom-free, had no medical complaints and had a normal ECG pattern. Discussion. There are several reports of coronary artery perforation during or following PCI. Its incidence may differ from center to center. In one of the largest series from a single center, the incidence was 0.40% in women and 0.22% in men undergoing PCI.2 It occurs more frequently during tissue debulking or ablation using directional atherectomy, rotational atherectomy, excimer laser and transluminal extraction catheter atherectomy.7 However, the majority of cases involve complications from balloon angioplasty and stenting caused by the guidewire or the use of oversized balloons, with a mismatch between the coronary artery diameter and balloon diameter.2 Patients with heavily calcified, tortuous arteries or noncompliant arteries, as well as women and the elderly, are particularly at risk. It is more frequent in the left circumflex and right coronary arteries, in longer lesions (> 10 mm) and in eccentric lesions.7–9 The case reported here is of particular interest not only because a coronary perforation rarely occurs in the LAD of a young male during PCI, but also because a pseudoaneurysm formation associated with coronary dissection has been described in only a few case reports. Actually, the incidence and its causes after PCI still remain unclear.10 In the present case, a diffuse and fibrotic LAD lesion was perforated during high-pressure balloon inflation and balloon rupture. It worth noting that associated risk factors such as dyslipidemia, heavy cigarette smoking and opium use may contribute to damage of the internal elastic lamina and weaken the vascular wall even more. Local effects of balloon perforation, accompanied by a chronic acquired degenerative defect in the vessel wall, can lead to the development of coronary pseudoaneurysm. This case report describes the early development of a pseudoaneurysm after DES implantation and the anatomic information provided by subsequent IVUS. The main therapeutic strategy for coronary artery perforation is prolonged inflation with either an angioplasty balloon or a perfusion catheter. Other alternatives include emergency bypass surgery for drainage and artery repair, bare-metal stenting, polytetrafluoroethylene-covered stenting or autologous vein graft-covered stenting, which has been successfully used in a limited number of cases. Perfusion balloons will occlude the hole, seal the defect, permit distal vessel perfusion and reduce ischemia during the prolonged inflation.2 In our patient, the LAD perforation was primarily sealed by the balloon inflation. Since our patient had a diffuse lesion with overlapping stents and was hemodynamically stable, we decided to delay any invasive intervention. Furthermore, a stent graft was not implemented due to a higher risk of restenosis, stent thrombosis and the fact that the perforation had been sealed. During close observation, clinical examinations and imaging studies revealed resolution of the pseudoaneurysm. However, the natural history and therapeutic strategy for coronary aneurysm/pseudoaneurysm are uncertain and a “preferred treatment” is not known.10 Conclusion. A conservative approach with watchful waiting and repeat angiography and IVUS are extremely helpful to diagnose and plan the therapeutic approach for patients who develop coronary perforation and pseudoaneurysm due to PCI. However, a pseudoaneurysm after iatrogenic coronary perforation is very rare, and its appropriate management remains uncertain.

2. Gruberg L, Pinnow E, Flood R, et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680–682.

3. Topaz O, Cowley MJ, Vetrovec GW. Coronary artery perforation during angioplasty: Angiographic detection and demonstration of complete healing. Cathet Cardiovasc Diagn 1992;27:284–288.

4. Gunning MG, Williams IL, Jewitt DE, et al. Coronary artery perforation during percutaneous intervention: Incidence and outcome. Heart 2002;88:495–498.

5. Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneurysms after drug-eluting stent implantation. Am Coll Cardiol Intv 2008;1:14–21.

6. Ellis SG, Vandormael MG, Cowley MJ, et al, and the Multivessel Angioplasty Prognosis Group. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease: Implications for patient selection. Circulation 1990;82:1193–1202.

7. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: Incidence, classification, management, and outcome. Circulation 1994;90:2725–2730.

8. Cohen BM, Weber VJ, Reisman M, et al. Coronary perforation complicating rotational ablation: The U. S. multicenter experience. Cathet Cardiovasc Diagn 1996;(Suppl)3:55–59.

9. Reimers B, Von Birgelen C, van der Giessen WJ, Serruys PW. A word of caution on optimizing stent deployment in calcified lesions: Acute coronary rupture with tamponade. Am Heart J 1996;131:192–194.

10. Cafri C, Gilutz H, Kobal S, et al. Rapid evolution from coronary dissection to pseudoaneurysm after stent implantation: A glimpse at the pathogenesis using intravascular ultrasound. J Invasive Cardiol 2002;14:286–289.