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Year : 2012  |  Volume : 15  |  Issue : 2  |  Page : 158-160
Cardiac computed tomography as a diagnostic tool for coronary artery aneurysm following percutaneous coronary intervention


CTVS Department, Sahara Hospital, Gomti Nagar, Lucknow, Uttar Pradesh, India

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Date of Web Publication16-Apr-2012
 

How to cite this article:
Darbari A, Singh D, Tandon S. Cardiac computed tomography as a diagnostic tool for coronary artery aneurysm following percutaneous coronary intervention. Ann Card Anaesth 2012;15:158-60

How to cite this URL:
Darbari A, Singh D, Tandon S. Cardiac computed tomography as a diagnostic tool for coronary artery aneurysm following percutaneous coronary intervention. Ann Card Anaesth [serial online] 2012 [cited 2019 Dec 15];15:158-60. Available from: http://www.annals.in/text.asp?2012/15/2/158/95082


The formation of a coronary artery aneurysm (CAN) after percutaneous coronary intervention (PCI) is a rare complication and new entity, but these are frequently associated with adverse clinical events as a result of stent restenosis and stent thrombosis. [1],[2],[3],[4] We are reporting a case of CAN following drug-eluting stent (DES) after PCI, which is very well diagnosed and featured by cardiac computed tomography (CCT). By using this diagnostic modality, this rare entity may be detected even in asymptomatic patients. [5]

A 55-year-old man presented with unstable angina after a 6-month history of exertional chest pain. His medical history included dyslipidemia, hypertension and smoking, with significant family history of coronary artery disease.

Transthoracic echocardiography showed normal left ventricular systolic function and no remarkable structural abnormalities but regional wall abnormality in the left anterior descending (LAD) artery territory. Coronary angiography (CAG) revealed focal stenosis in the proximal LAD and right coronary artery (RCA), for which interventions were performed. Both the lesions predilated, after which 3.0 mm × 16 mm DESs were deployed.

The patient experienced severe chest pain just after 3 days of the initial PCI, and he was taken for repeat CAG. The RCA stent remained widely patent. However, just outside of the initial portion of the LAD stent, there was a small contrast collection, which was suspected as a pseudoaneurysm. Subsequent CCT showed a 4 mm × 4 mm pseudoaneurysm at the midportion of the LAD stent involving Diagonal-1 branch (D1) origin but away from the left circumflex (LCX) artery [Figure 1] and [Figure 2]. The RCA stent was normal and with no abnormality [Figure 3].
Figure 1: Cardiac computed tomography image of the left anterior descending artery aneurysm in relation of left circumflex artery

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Figure 2: Cardiac computed tomography image of the left anterior descending artery aneurysm involving the diagonal-1 branch at origin

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Figure 3: Cardiac computed tomography image of the left anterior descending artery aneurysm and patent right coronary artery stent without any abnormality

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The patient had further recurrent chest pain episodes. Thus, in view of the symptomatic nature of the patient, surgical repair and revascularization was indicated for the patient. [6] Three-dimensional reconstruction images by CCT helped for treatment plan [Figure 4]. Plication of the coronary aneurysm and coronary artery bypass grafting were performed through a median sternotomy using cardiopulmonary bypass and hypothermic blood cardioplegia. D1 was bypassed with the reverse saphenous vein graft. The stent was not removed but the aneurysm was closed proximally and distally tightly with a 5-0 polypropylene running mattress suture. Distal LAD was bypassed with the left internal mammary artery (LIMA). Bypass recovery was very smooth with no electrocardiographic changes. The patient underwent an uneventful recovery and was discharged 7 days after the operation. The patient is on regular follow-up for the last 1 year, with no complication and morbidity.
Figure 4: Three-dimensional reconstruction of cardiac computed tomography image of the left anterior descending artery aneurysm in relation of the left circumflex artery

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Coronary aneurysms after DES implantation are rarely detected (1.25%), and coronary angiography is able to provide an accurate diagnosis of this entity. [2],[3] The role of DES in the formation of coronary aneurysm is controversial. Although the underlying mechanism for CAN development remains unknown, several hypotheses as acute extensive vessel wall injury, hypersensitivity reactions, focal infectious processes, vessel remodeling and DES malapposition are postulated. [4]

CCT has the limitation of availability of equipment and personnel with interpretation facility, and is also not indicated for patients with irregular rhythms, refractory tachycardia, extreme obesity, renal insufficiency and presence of metallic interference. As per ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006, appropriateness criteria for CCT are only larger stents (3 mm in diameter) or with left main stents, imaging of stents considered indicated and appropriate. [5]

After PCI, CAN can be diagnosed and this imaging advancement presents a new opportunity to utilize non-invasive technique to gain important clinical information. Intravascular ultrasound also provides diagnosis into further anatomic insights, including the extent of DES malposition, which may also have major prognostic implications. [4],[5]


   Acknowledgement Top


We are thankful to the Radiology Department, Sahara Hospital, Gomti Nagar, Lucknow, for data collection, interpretation and reproduction.

 
   References Top

1.Yip HK, Chen MC, Wu CJ, Hang CL, Hsieh KY, Fang CY, et al. Clinical features and outcome of coronary artery aneurysm in patients with acute myocardial infarction undergoing a primary percutaneous coronary intervention. Cardiology 2002;98:132-40.  Back to cited text no. 1
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2.Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneurysms after drug-eluting stent implantation. JACC Cardiovasc Interv 2008;1:14-21.  Back to cited text no. 2
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3.Nohara H, Shida T, Mukohara N, Obo H, Yoshida M. A case of the coronary artery aeurysm including stent device after percutaneous coronary intervention. Ann Thorac Cardiovasc Surg 2004;10:202-4.  Back to cited text no. 3
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4.Alfonso F, Pérez-Vizcayno MJ, Ruiz M, Suárez A, Cazares M, Hernández R, et al. Coronary aneurysms after drug-eluting stent implantation: Clinical, angiographic, and intravascular Ultrasound Findings. J Am Coll Cardiol 2009;53;2053-60.  Back to cited text no. 4
    
5.Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O'Gara P, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation 2010;122:e525-55. Available from: http://www.circ.ahajournals.org/content/122/21/e525. [Last accessed on 2011 Sept 7].  Back to cited text no. 5
    
6.Yamaguchi H, Yamauchi H, Yamada T, Ariyoshi T. Surgical repair of coronary artery aneurysm after percutaneous coronary intervention. Jpn Circ J 2001;65:52-5.  Back to cited text no. 6
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Correspondence Address:
Anshuman Darbari
23/36 Govind Nagar, Bengali Mandir Road, Rishikesh 249 201, Dist. Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.95082

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    Figures

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