Successful Exclusion of a Left Main Coronary Artery Aneurysm
with a PTFE-Covered Coronary Stent

Coronary artery aneurysm (CAA), defined as localized coronary dilatation with a diameter >= 1.5 times that of the adjacent normal coronary segment, is observed in 0.2–4.9% of patients undergoing coronary angiography.1–6 CAA most often involves the right coronary artery, followed in frequency by the left anterior descending (LAD )and rarely involving the left main coronary artery.6–10 Although most CAAs are atherosclerotic in origin, other etiologies include congenital aneurysms, Kawasaki disease, connective tissue disorders, infectious arteritis and coronary trauma, including that related to percutaneous coronary intervention (PCI).1 The majority of patients with CAA are asymptomatic, but associated symptoms related to distal coronary thromboembolism, atherosclerotic stenoses, secondary extrinsic native vessel compression, coronary spasm or rupture can occur.1–6 There are multiple reports in the literature regarding CAA incidence, pathogenesis, clinical outcome and treatment.1–12 The prognosis of patients with atherosclerotic coronary aneurysm is in large part related to the presence and severity of associated coronary stenoses. If asymptomatic, the progression, rupture or secondary embolization rates are unpredictable and poorly defined. Treatment strategies have focused on surgical resection/exclusion or medical therapy with anticoagulant or antiplatelet agents.1–12 More recently, percutaneous catheter-based therapy has evolved to include coil embolization with thrombotic occlusion or sealing of the aneurysm from the coronary lumen through the use of a covered stent prosthesis.13–20 Covered stents have been constructed by suturing harvested segments of autologous vein or artery on currently available stent devices or by manufacturing stents covered with artificial polytetrafluoroethylene (PTFE) material.13–27 We previously reported the successful deployment of an autologous vein-covered stent to exclude a left main coronary atherosclerotic aneurysm.26 Strozzi et al. recently reported percutaneous obliteration of a left main CAA utilizing the Jomed PTFE-covered stent.27 The present report describes the second case of an unprotected left main CAA successfully excluded by a PTFE-covered coronary stent and provides angiographic follow-up at 6 months and 1 year. Case Report. A 58-year-old man was referred in September 2001 for evaluation and treatment of progressive angina. Cardiac risk factors included a positive family history of coronary artery disease, a history of hypertension, hypercholesterolemia and current tobacco use. Noninvasive stress testing revealed multiple areas of reversible ischemia and the patient was referred for diagnostic cardiac catheterization. Angiography demonstrated a 70% ulcerative left main coronary artery with nonobstructive atherosclerosis in the other major epicardial vessels. Left ventricular function was preserved and surgical revascularization was recommended. The patient underwent off-pump coronary artery bypass surgery (CABG) in September 2001, which included a left internal mammary artery graft to the LAD and a sequential radial free graft to the circumflex first and second obtuse marginal arteries constructed as a “T” graft from the internal mammary artery. His post-operative course was uneventful. The patient subsequently presented in August 2002 with recurrence of angina, paroxysms of atrial fibrillation and an abnormal graded exercise test. Diagnostic cardiac catheterization demonstrated preserved left ventricular function, complete occlusion of the left internal mammary artery graft to the LAD and subsequent failure of the radial graft to the circumflex artery distribution. An aneurysm of the left main coronary artery was observed at the site of prior plaque fissure (Figure 1). Options of repeat surgical revascularization versus catheter-based treatment were discussed in detail with the patient; he elected to participate in an ongoing clinical registry evaluating the Jomed PTFE-covered coronary stent for aneurysm exclusion. PCI was performed utilizing an intra-aortic balloon pump for hemodynamic support due to the unprotected left main coronary target vessel. Selective left coronary angiography was performed using an 8 French Judkins left 5-curve short-tip guiding catheter, at which time a 0.014´´ Super Soft stabilizer guidewire (Cordis Corporation, Miami, Florida) was passed into the LAD and intravascular ultrasound measurements were obtained of the left main coronary aneurysm. A 4.0 x 12 mm Jomed stent was then deployed in the left main coronary artery (Figure 2) and post-dilated with a noncompliant balloon to 16 atmospheres. Post-deployment selective angiography demonstrated 0% residual stenosis and no evidence of residual aneurysm at termination of the procedure (Figure 3). Intravascular ultrasound demonstrated excellent apposition and symmetry of the Jomed stent in the left main coronary artery. Follow-up coronary angiography at 6 months (Figure 4) and 1 year (Figure 5) demonstrated a widely patent left main coronary artery with no evidence of aneurysm recurrence. Discussion. To our knowledge, this is the second reported case of percutaneous exclusion of an unprotected left main CAA utilizing the Jomed PTFE-covered coronary stent. Several prior reports described successful closure of CAAs using PTFE-covered stents in arteries previously treated with PCI or emergently for coronary perforation or rupture.21–25 This patient developed an atherosclerotic CAA involving the left main coronary artery following CABG, with subsequent graft failure and recurrence of anginal symptoms. Interestingly, the CAA developed at the site of a previous ulcerated lesion of the left main coronary artery that was present prior to bypass surgery. This case supports prior observations that vascular aneurysms may be successfully excluded by percutaneous deployment of covered stent graft technologies.13–27 Although coronary perforation and aneurysm in coronary-caliber vessels have been successfully treated by PTFE-covered stents, large data sets are not available with these devices in aneurysmal disease, especially of the left main coronary artery, due to the infrequent occurrence. Harvested segments of radial artery as well as brachial or saphenous vein have also been used to cover commercially available stents to obliterate sites of arterial perforation or aneurysm formation.14–20 Our case is enhanced by serial late coronary angiography, which demonstrated no evidence for late restenosis or recurrence of aneurysmal disease. Ongoing registry data and clinical experience with these devices will help define specific patient populations and optimal strategies for their use in PCI.

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