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Intravascular Ultrasound Guidance of Multiple Drug-Eluting Stent Implantation in Lesions Associated with Coronary Aneurysms
From the Interventional Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 8, 2008 provisional acceptance given January 13, 2009, and final version accepted February 9, 2009. Address for correspondence: Fernando Alfonso, MD, Cardiología Intervencionista, Instituto Cardiovascular, Hospital Universitario Clínico “San Carlos”, Ciudad Universitaria, Plaza Cristo Rey, Madrid 28040, Spain. E-mail: falf@hotmail.com
_________________________________________________ ABSTRACT: Treatment of lesions associated with coronary artery aneurysms (CAA) remains a challenge. This is especially true in patients presenting with multiple CAA. We, therefore, describe a case of a 48-year-old male with severe multivessel disease related to CAA who was treated using drug-eluting stents to address the stenoses located at the CAA edges. The value of intravascular ultrasound to guide and optimize the results of this complex intervention is emphasized.
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J INVASIVE CARDIOL 2009;21:E77–E80 Coronary artery aneurysms (CAA) are uncommon findings during routine diagnostic coronary angiography.1–4 CAAs are usually defined as the dilatation of a coronary artery segment that exceeds 1.5 times the diameter of a normal adjacent reference segment.1 The incidence of CAA has been reported to be between 1.5–5%, with half of the patients having multivessel involvement.1 Predictors for developing a CAA include male gender, hyperlipidemia and cocaine use, with the right coronary artery (RCA) being the vessel most frequently affected.1–7 CAAs can be congenital (17%) or acquired (83%).5 The most frequent etiology of acquired CAA remains atherosclerosis, whereas Kawasaki disease should always be suspected in children.2 Acquired CAA may also be iatrogenic and may occur after percutaneous coronary intervention (PCI) with balloon angioplasty, directional atherectomy, intracoronary beta-irradiation and stent implantation (both bare-metal stents [BMS] and drug-eluting stents [DES]).8–14 To date, there is no definite clinical evidence of the prognosis of CAA or the optimum treatment strategy for these patients. Most of what is known about prognosis and potential treatment has been based on case reports and anecdotal experience. PCI with stents20–23 and surgical revascularization24,25 have both been recognized as acceptable forms of revascularization in selected patients. PCI to vessels with CAA is a complex and challenging procedure, especially in patients with coronary stenoses at the edges of the CAA. The challenge in performing PCI in this group of patients is to minimize the amount of stent protrusion into the CAA resulting in incomplete stent apposition. Angiographically, it is impossible to precisely visualize stent location and apposition against the vessel wall. However, intravascular ultrasound (IVUS) does constitute the method of choice to visualize stent location and the presence of malapposition. We describe a complex case of a patient with severe coronary artery disease at the edges of multiple CAAs who underwent PCI with deployment of several DES. IVUS was used to monitor and optimize the procedural results. Case Report. A 48-year-old male with a history of cigarette smoking, noninsulin-dependent diabetes mellitus and hyperlipidemia was admitted to another hospital with a 1-hour history of left precordial chest discomfort. The 12-lead electrocardiogram (ECG) showed 1–2 mm ST-elevation on leads V2–V6. Thrombolytic therapy (TNK) was administered 2 hours after the onset of pain, followed by fractioned heparin and dual antiplatelet therapy (aspirin and clopidogrel). His peak creatine kinase was 1,300 U/L (normal 15,16 Overall, the treatment of CAA remains challenging and controversial in terms of optimum treatment, as well as the type of stent to be implanted. Our case illustrates the value of the unique insights provided by IVUS in this setting. More studies and new innovative strategies are required to address the management of this important coronary artery pathology.
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