Author + information
- Received July 3, 2018
- Accepted July 10, 2018
- Published online September 17, 2018.
- aDivision of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- bSchool of Medicine, Tzu Chi University, Hualien, Taiwan
- ↵∗Address for correspondence:
Dr. Yu-Lin Ko, Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 289 Jiang Kuo Road, Xindian District, New Taipei City 231, Taiwan.
A 65-year-old man was admitted for angina pectoris and evidence of anteroseptal myocardial ischemia on perfusion imaging. Angiography revealed a large left anterior descending (LAD) coronary artery aneurysm (CAA) arising 2 mm distal to the bifurcation of a large first diagonal branch (Figure 1A). A 3.5 × 19-mm polytetrafluoroethylene covered stent (Graftmaster, Abbott Vascular, Santa Clara, California) was implanted to seal off the aneurysm. The covered stent effectively straddled the aneurysm with the proximal stent edge positioned just distal to the bifurcation to avoid compromising the first diagonal branch (Figure 1B). The procedure ended with a small leak of sluggish blood flow into the CAA with very faint opacification (Figure 1C, Online Video 1).
Six hours later, the patient developed sudden onset of severe chest pain with dyspnea and diaphoresis. Electrocardiography showed ST-segment elevation in V1 to V4. Immediate coronary angiography revealed prolapse of the covered stent into the CAA, resulting in obstruction of the LAD (Figure 1D, Online Video 2). The coronary wire first went into the CAA (Figure 1E) and then redirected into the LAD. A 3.5 × 38-mm drug-eluting stent (Xience Xpedition, Abbott Vascular) was deployed across the covered stent to secure its position (Figure 1F). Final angiography showed complete isolation of the CAA (Figure 1G). The patient remained free from angina at 18-month follow-up.
The proposed mechanism of covered stent prolapse into the CAA was the short landing zone in which the proximal stent edge acted as a fulcrum for the stent strut, causing the stent to migrate into the CAA due to significant LAD motion during the cardiac cycle. For symptomatic CAA, covered stent implantation promotes aneurysm hemostasis and thrombosis. However, branch artery compromise remains a concern. The double-stent method, in which one stent is placed within another, is a feasible method of promoting aneurysm thrombosis and acts to secure the position of the covered stent if the landing zone is too short due to nearby major branch arteries.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 3, 2018.
- Accepted July 10, 2018.
- 2018 American College of Cardiology Foundation