ICUS-Guided Obliteration of a Complex Coronary Artery Aneurysm with a PTFE-Covered Stent

Angiographically detected coronary artery aneurysms are difficult to treat; they occur with an incidence of 0.3–4.9% (2–10% after interventional procedures).1,2 They can provoke ischemia1 or myocardial infarction.3 Several cases of covered stent implantation for the treatment of coronary aneurysms in native and aorto-coronary venous bypass grafts have been reported.4,5 The Jostent® Coronary Stent Graft (Jomed, International AB, Helsingborg, Sweden) has a polytetrafluoroethylene (PTFE) membrane and is indicated for sealing of coronary perforations6 and obliteration of coronary aneurysms or fistulas. Intracoronary ultrasound (ICUS), in addition to coronary angiography, provides precise measurements of coronary wall dimensions and therefore allows detailed characterization of the coronary artery aneurysm’s dimensions.7 We present a patient in whom the imaging ability of ICUS and the technical property of the covered stent were combined for successful treatment of a complex coronary artery aneurysm. Case Report. A 74-year-old woman with a history of hyperlipidemia, smoking and arterial hypertension presented with unstable angina. Her current cardiac medication consisted of beta-blocking agents, ACE inhibitors, nitrates, diuretics and long-term treatment with aspirin (100 mg/day). Diagnostic catheterization 6 months prior revealed coronary artery disease (Canadian Cardiovascular Society Class 2) with a hemodynamically relevant stenosis in the right coronary artery. The patient underwent stent implantation in this segment at that time. In addition, coronary angiography revealed a coronary artery aneurysm in the distal part of the circumflex artery. Coronary angiography revealed an increase of the pre-existing aneurysm. Covered by the aneurysm, an obtuse marginal branch arose from the circumflex artery. Neither the exact dimensions of the aneurysm nor the wall morphology in the ostium of the branching vessel were angiographically detectable. After intracoronary injection of 0.25 mg nitroglycerin, ICUS was performed by manual advancement and standardized motorized pullback system at a speed of 0.5 mm/s with a 2.9 French (Fr) system and a 30 MHz transducer-tipped catheter (Ultracross Cardiovascular Imaging System, CVIS, Sunnyvale, California). Additional application of contrast dye revealed the exact dimensions and characteristics of the aneurysm and its relation to the branching vessel. The aneurysm was circular, with a central high-grade stenosis. The smallest lumen site was demarcated by a calcium-containing plaque with lateral shadowing. ICUS investigation revealed a pseudoaneurysm (Figure 1). Standard percutaneous transluminal coronary angioplasty was performed after application of 10,000 IU intravenous heparin. An 8 Fr Judkins guiding catheter (Cordis Corporation, Miami, Florida) and a 0.014´´ guidewire (Advanced Cardiovascular Systems, Inc., Temecula, California) were used. Predilation was performed at 8 atmospheres (atm) for 60 seconds according to the ICUS information with a 3.0 x 20 mm compliant Omnipass balloon (Cordis Corporation). ICUS-guided stent implantation was performed with a 3.0 x 12 mm Jostent® covered stent inflated at 18 atm for 60 seconds. ICUS revealed unhampered flow in the branching vessel in consideration of the obtuse marginal branch. However, beside bare stent struts in the coronary lumen, the stent diameter was not adjusted to the reference vessel (Figure 2). Additional stent optimization with a 4.0 x 9 mm high-pressure Chubby balloon (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) at 18 atm for 20 seconds resulted in optimal stent expansion according to quantitative and qualitative angiographic and sonographic criteria. The final angiogram demonstrated appropriate lumen and stent dimensions with complete coverage of the aneurysm and successful protection of the obtuse marginal branch. The neolumen of the aneurysm was nearly eliminated (Figure 3). Follow-up exam 4 months later demonstrated well preserved lumen and stent dimensions (Figure 4). Discussion. Coronary dilation due to aneurysms with different etiologies represents a rare disorder. There is controversy as to whether or not coronary aneurysms go on to rupture and which, if any, require treatment. Recent studies with a small sample size demonstrated the effectiveness and usefulness of PTFE-covered stents in the treatment of coronary artery aneurysms.4,8,9 However, the indications for treatment and the appropriate therapies still need to be defined. In our report, we present the combined use of covered stent implantation and ICUS for the treatment of a complex coronary artery aneurysm. We can confirm the positive results of recent studies using covered stents for the treatment of coronary aneurysms. The PTFE-covered stent was able to be well placed and optimized in relation to the reference vessel. The aneurysm was completely covered and the neolumen was subsequently eliminated. ICUS provided beneficial information in addition to coronary angiography regarding the exact length dimensions of the aneurysm and the exact location of the obtuse marginal branch, resulting in the protection of this vessel. The choice of balloon and stent dimension was directly dependent upon sonographic online analysis, resulting in adequate lumen and stent dimensions after stent implantation and satisfying long-term patency. Conclusion. The covered stent is beneficial for the treatment of coronary artery aneurysms and may reduce the need for surgical treatment in these patients. The status of intracoronary ultrasound in the treatment of complex coronary morphologies was highlighted on the basis of this patient report.

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