Cardiovasc Interv and Ther DOI 10.1007/s12928-015-0338-0

CASE REPORT

A case of coronary rupture and pseudoaneurysm formation after fracture of implanted paclitaxel-eluting stents Yasuyuki Kawai1 • Michihiko Kitayama2 • Hironobu Akao1 • Atsushi Motoyama1 Taketsugu Tsuchiya2 • Kouji Kajinami1



Received: 27 October 2014 / Accepted: 12 May 2015  Japanese Association of Cardiovascular Intervention and Therapeutics 2015

Abstract A 48-year-old man who had undergone implantation of two paclitaxel-eluting stents (PESs) at the right coronary artery was admitted to our hospital with progressive dyspnea. In the coronary care unit, he developed cardiogenic shock due to cardiac tamponade treated by pericardiocentesis. A coronary angiogram showed a large pseudoaneurysm at the site of the previously implanted stents, suggesting coronary rupture due to implanted stent fracture. The pseudoaneurysm was completely sealed by polytetrafluoroethylene-covered stent implantation. Although this case is very rare, coronary rupture by stent fracture should be considered when cardiac tamponade occurs after drug-eluting stent implantation, especially PES. Keywords Coronary rupture  Pseudoaneurysm  Percutaneous coronary intervention  Paclitaxel-eluting stent  Polytetrafluoroethylene-covered stent

Introduction A life-threatening coronary rupture with subsequent coronary pseudoaneurysm formation after DES implantation is a very rare event. Some therapeutic strategies such as medical therapy, observation [1], surgical therapy [2–8], coil embolization [9–11], and PTFE-covered stent implantation are available for the treatment of coronary pseudoaneurysm. & Yasuyuki Kawai [email protected] 1

Department of Cardiology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa 920-0293, Japan

2

Division of Cardiovascular Intervention, Kanazawa Medical University, Ishikawa, Japan

A case of coronary rupture with cardiac tamponade and subsequent coronary pseudoaneurysm formation at the site of PES implantation 4 years earlier, and complete sealing of the pseudoaneurysm by PTFE-covered stent implantation is reported. The patients’ characteristics, potential causes, and clinical outcomes of reported cases of coronary pseudoaneurysm at the implanted DES site were also reviewed.

Case report A 48-year-old man developed an acute viral upper respiratory infection 2 weeks before admission and was admitted to our hospital with progressive dyspnea 3 days after an episode of severe chest pain after a bowel movement in July 2013. His medical history included WHO class II obesity (body mass index 35.1 kg/m2), diabetes mellitus (DM) type II, protein S deficiency, and bilateral deep vein thromboses. The patient had undergone two overlapped PES (3.0 mm 9 20 mm and 3.0 mm 9 32 mm Taxus Liberte, Boston Scientific, Place Natick, MA, USA) implantations at the site of a chronic total occlusive lesion in the mid-right coronary artery in March 2009 (Fig. 1a,b), and he was taking aspirin, clopidogrel, and warfarin since then. On admission, his heart rate was 74 beats/min (bpm), and his blood pressure was 90/50 mmHg. His heart sounds were diminished. However, he did not have pulsus paradoxus. Laboratory findings showed anemia, C-reactive protein elevation, renal dysfunction, and hyperglycemia. The prothrombin time-international normalized ratio was prolonged at 3.93. Troponin T was slightly elevated, and blood gas analysis showed marked hypoxia. The electrocardiogram (ECG) showed slight ST elevation in leads II, III, aVF, V5, and V6, and low voltage in the limb leads (Fig. 2a). The chest X-ray showed marked cardiomegaly,

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Fig. 1 a Pre-PCI right coronary angiogram in March 2009. b The final angiogram after implantation of two paclitaxel-eluting stents. White arrows indicate the two implanted PESs

slight pulmonary congestion, and a pleural effusion. Chest CT showed pericardial and bilateral pleural effusions (Fig. 2b). Echocardiography showed the pericardial effusion as seen on the CT (Fig. 2c). At that time, the diagnosis was suspected to be either acute pericarditis due to the preceding upper respiratory infection and ECG findings or a hemopericardial effusion due to dual antiplatelet therapy (DAPT) and excessive warfarin. His hemodynamics stabilized with oxygen and catecholamine therapy. Therefore, it was decided to discontinue DAPT and warfarin and follow the patient. However, the next day, he developed cardiogenic shock due to cardiac tamponade with a large pericardial effusion on echocardiography (Fig. 2d). His vital signs improved after drainage of about 1.5 L of bloody fluid by pericardiocentesis. The final follow-up CAG in April 2013 showed no restenosis at the site of the previously implanted stents (Fig. 3a). However, to determine the cause of the previous episode of severe chest pain and pericardial effusion, CAG was performed on the 14th hospital day. The CAG showed a large aneurysm at the previous stent implantation site, which could have been a cause of cardiac tamponade (Fig. 3b, c). The contrast CT imaging after CAG showed the enhanced aneurysm adjacent to the pericardial cavity (Fig. 3d). Because of the potential risk of another rupture, a percutaneous coronary intervention (PCI) was performed to treat the aneurysm. A 7-Fr Amplatz left 1.0 guiding catheter (Launcher, Medtronic, Santa Rosa, CA, USA) was engaged at the RCA. A 0.014-inch soft wire (Proneur soft, Zeon Medical, Tokyo, Japan) was inserted into the RCA. The optical coherence tomography (OCT) imaging at the site of the aneurysm showed disappearance of the stent structure

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and vessel walls (Fig. 4a, b, c). The findings were confirmed by 3D imaging (Fig. 4d). To verify whether the aneurysm was a pseudoaneurysm, intravascular ultrasound (IVUS) was performed (Eagle Eye Gold Catheter, Volcano, San Diego, CA, USA). IVUS imaging at the site of aneurysm showed lack of the wall’s vascular layers and stent structure and formation of a fibrous wall continuing with the structure of the adjacent vascular wall; the ChromoFlo imaging showed blood flow into the aneurysm, indicating that the aneurysm was a pseudoaneurysm (Fig. 4e, f, g). The pseudoaneurysm did not disappear with 10 min of inflation by a 3.5 mm 9 20 mm perfusion balloon (Ryusei, Kaneka, Osaka, Japan). The pseudoaneurysm was then completely sealed by PTFE-covered stent (3.0 mm 9 16 mm JoStent Graftmaster, Abbott Vascular, Santa Clara, CA, USA) implantation (Fig. 5a,b). After covered stent implantation, the 3D OCT imaging showed complete sealing of the pseudoaneurysm (Fig. 5c). CAG at 6-month follow-up showed persistent sealing of the pseudoaneurysm and focal restenosis at the proximal edge of the implanted covered stent, which was followed by cutting balloon (3.0 mm 9 10 mm, Flextome, Boston Scientific) inflation. The patient then remained well without ischemia.

Discussion In the present case, although there was no direct evidence of coronary rupture leading to cardiac tamponade, IVUS, OCT, and contrast CT imaging strongly suggested that cardiac tamponade was induced by coronary rupture due to stent fracture and subsequent pseudoaneurysm formation.

A case of coronary rupture and pseudoaneurysm formation after fracture of implanted…

Fig. 2 a Electrocardiogram on admission. Heart rate is 76 bpm. Slight ST elevation in leads II, III, aVF, V5, and V6, and low voltage in the limb leads are shown. b Chest CT showing the pericardial

effusion on admission. Echocardiography obtained in the subxiphoid position also showing the pericardial effusion c on admission, and d on the second hospital day

It has been reported that the incidence of coronary artery aneurysm after DES implantation ranges from 0.3 to 4.5 % [12]. Compared with coronary artery aneurysm, only 11 cases of coronary pseudoaneurysm after DES implantation have been reported in the English-language literature [1– 11]. Table 1 shows a review of the reported cases of coronary pseudoaneurysm at the implanted DES site. In 1 of the 11 cases, it was reported that the coronary rupture due to fracture of the DES caused cardiac tamponade leading to coronary pseudoaneurysm formation (case 7 in Table 1), as in the present case [6]. The timing of pseudoaneurysm appearance was within 10 months in each case. In the present case, coronary

rupture and subsequent pseudoaneurysm formation occurred 4 years after the DES implantation. Therefore, this is the first case of very late pseudoaneurysm formation. The precise mechanisms for coronary pseudoaneurysm formation after DES implantation are unknown. In the reviewed cases, the cause of pseudoaneurysm was infection in three cases, etiology unknown but suspected trauma or dissection of the coronary artery in four cases, and stent fracture in two cases. Most (8 of 11 cases) patients were implanted with a PES. Therefore, differences in coated drugs and/or polymers may be implicated in pseudoaneurysm formation. As for the stent fracture, of the postulated risk factors for stent fracture [13], stenting at the RCA, a longer stent, and an overlapped stent

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Fig. 3 a Follow-up CAG showing no significant restenosis at the site of the implanted PES in April 2013. Coronary angiograms showing a large aneurysm at the site of the implanted stent b in the LAO view

and c the RAO view. d Contrast chest CT showing the enhanced aneurysm adjacent to the pericardial cavity (white arrow)

resulting in hinge movement might have induced the stent fracture in the present case. Furthermore, since the patient experienced severe chest pain after a bowel movement, the elevation of heart rate and blood pressure by straining at stool leading to direct mechanical stress due to more hinge movement during the cardiac cycle and mechanical fatigue of the stent metal structure for 4 years might have been related to the stent fracture. On the other hand, the coated paclitaxel and/or polymer might be implicated in coronary rupture after stent fracture. Unlike inhibitors of mammalian target of rapamycin (mTOR) such as sirolimus, zotarolimus, and everolimus, paclitaxel can exert cytotoxicity leading to vascular injury, necrosis, and apoptosis by arresting the cell cycle at the mitosis

(M) phase through centrosomal impairment, induction of abnormal spindles, and suppression of spindle microtubule dynamics [14]. Furthermore, paclitaxel accumulates in the adventitia, the last layer that protects the vessel walls from rupture, as compared with sirolimus, which distributes equally within the vascular layers [15]. A polymer may also weaken vessel walls, because the coated polymer can be associated with ongoing vascular inflammation and delayed vascular healing [16–18]. Therefore, coronary rupture and subsequent pseudoaneurysm formation in the present case might have been induced not only by stent fracture but also by weakness of the vessel walls induced by the paclitaxel and/or polymer coating.

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A case of coronary rupture and pseudoaneurysm formation after fracture of implanted…

Fig. 4 a, b, c Optical coherence tomography (OCT) and e, f, g intravascular ultrasound images from the distal portion of the aneurysm before PTFE-covered stent implantation showing the

disappearance of stent structure and vessel walls at the site of the aneurysm. d 3D OCT imaging of the figure

Almost all cases underwent surgical treatment by ligation of the proximal and distal portions of the pseudoaneurysm and distal bypass. Three cases were treated with coil embolization of the pseudoaneurysm. In the present case, the patient had some risks for surgery, such as DM type II, bilateral deep vein thromboses, protein S

deficiency, and marked obesity. Therefore, it was decided to treat the pseudoaneurysm by PCI. However, a coil was not used to treat the pseudoaneurysm, because the guide wire could easily perforate the wall of a fresh pseudoaneurysm leading to a second episode of cardiac tamponade. Furthermore, we initially hesitated to use a PTFE-covered

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Fig. 5 a A 3.0 mm 9 16 mm PTFE-covered stent is implanted at the site of the pseudoaneurysm. b The final angiogram showing complete sealing of the pseudoaneurysm. c 3D OCT imaging after PTFE-covered stent implantation showing complete sealing of the pseudoaneurysm

stent, because of its low trackability due to the bulky profile produced by a sandwich-like structure, and its high rate of restenosis, mainly at the stent edge. It has been reported that the procedural success of a PTFE-covered stent was enabled by a large ([3.0 mm) vessel diameter and by the lack of in-stent intimal hyperplasia [19]. Fortunately, the present patient fulfilled the above conditions, and the procedure was successful in sealing the pseudoaneurysm. To the best of our knowledge, this may be the first case in which a pseudoaneurysm that occurred after DES implantation was treated with a PTFE-covered stent. There is no standard therapy for coronary pseudoaneurysm

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after DES implantation, but appropriate therapy should be determined according to the situation of each case.

Conclusions In conclusion, a case of coronary rupture and pseudoaneurysm formation after fracture of a PES that was implanted 4 years earlier was reported. Although very late coronary rupture and pseudoaneurysm formation are very rare complications, as in this case, coronary rupture by stent fracture should be considered when cardiac tamponade occurs after

A case of coronary rupture and pseudoaneurysm formation after fracture of implanted… Table 1 Review of reported cases of coronary pseudoaneurysms at the DES site References

Age (years)

Sex

Vessel

Timing

Type of DES

Cause

Treatment

Hagau et al. [2]

68

Male

LMC

6 mo

PES

Dissection?

Surgery

Candemir et al. [9]

54

Male

LCX

3 mo

PES

Unknown

Coil

Sandhu and Kaul [10]

72

Male

LCX

6 mo

PES

Fracture

Coil

Hori et al. [3]

73

Male

RCA

10 mo

PES

Overexpansion

Surgery

Furtado et al. [4]

62

Male

LAD

14 d

SES

Infection

Surgery

Kapoor et al. [5]

50

Male

LAD

2 mo

SES

Dissection?

Surgery Surgery

Choi et al. [6]

73

Male

RCA

3 mo

DES

Fracture

Chen et al. [1]

49

Male

LAD

1 mo

PES

Dissection?

Conservative

Le and Narins [7]

73

Male

LMC

4 mo

PES

Infection

Surgery

Maroo et al. [11]

45

Male

LCX

9 mo

PES

Unknown

Coil

Marcu et al. [8]

55

Male

LAD

3 mo

PES

Infection

Surgery

LMC left main coronary artery, LCX left circumflex artery, RCA right coronary artery, LAD left anterior descending artery, mo months, d days, DES drug-eluting stent, PES paclitaxel-eluting stent, SES sirolimus-eluting stent

DES implantation, especially PES. Finally, strict follow-up is needed, because PTFE-covered stents have higher restenosis and acute thrombosis rates than bare metal stents. Acknowledgments We acknowledge the contributions of Dr. R Saito and Dr. S Takano for their assistance with the procedure, and Mr. T Nakagawa and Mr. S Takama for their technical support in the catheterization laboratory. Conflict of interest

None declared.

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9. Candemir B, Altin T, Eda S, Durdu S, Ozcan OU, Akyurek O. Coronary rupture and pseudoaneurysm formation after extravascular migration of a paclitaxel eluting stent implanted in the left circumflex coronary artery. Herz. 2013;38:219–22. 10. Sandhu PS, Kaul U. Coronary stent fracture resulting in pseudoaneurysm. Indian Heart J. 2012;64:622–3. 11. Maroo A, Rasmussen PA, Masaryk TJ, Ellis SG, Lincoff AM, Kapadia S. Stent-assisted detachable coil embolization of pseudoaneurysms in the coronary circulation. Catheter Cardiovasc Interv. 2006;68:409–15. 12. Bajaj S, Parikh R, Hamdan A, Bikkina M. Covered-stent treatment of coronary aneurysm after drug-eluting stent placement. Tex Heart Inst J. 2010;37:449–54. 13. Doi H, Maehara A, Mintz GS, Tsujita K, Kubo T, Castellanos C, et al. Classification and potential mechanisms of intervascular ultrasound patterns of stent fracture. Am J Cardiol. 2009;103:818–23. 14. Wessely R, Schomig A, Kastrati A. Sirolimus and paclitaxel on polymer-based drug-eluting stents. Similar but different. J Am Coll Cardiol. 2006;47:708–14. 15. Levin AD, Vokmirovic N, Hwang CW, Edelman ER. Specific binding to intracellular proteins determines arterial transport properties for rapamycin and paclitaxel. Proc Natl Acad Sci USA. 2004;101:9463–7. 16. Hietala EM, Salminen US, Sta˚hls A, Va¨limaa T, Maasilta P, To¨rma¨la¨ P, et al. Biodegradation of the copolymeric polylactide stent. J Vasc Res. 2001;38:361–9. 17. Virmani R, Liistro F, Stankovic G, Mario CD, Montorfano M, Farb A, et al. A mechanism of late in-stent restenosis after implantation of a paclitaxel derivate-eluting polymer stent system in humans. Circulation. 2002;106:2649–51. 18. Goodwin SC, Yoon HC, Chen G, Abdel-Sayed P, Costantino MM, Bonilla SM, et al. Intense inflammatory reaction to heparin polymer-coated intravascular Palmaz stents in porcine arteries compared to uncoated Palmaz stents. Cardiovasc Intervent Radiol. 2003;26:158–67. 19. Vaghetti M, Palmieri C. A coronary pseudoaneurysm within a restenosis stent treated by implantation of a pericardium-covered stent and drug-eluting balloon. J Invasive Cardiol. 2013;25:E93–5.

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A case of coronary rupture and pseudoaneurysm formation after fracture of implanted paclitaxel-eluting stents.

A 48-year-old man who had undergone implantation of two paclitaxel-eluting stents (PESs) at the right coronary artery was admitted to our hospital wit...
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