Author + information
- Received August 11, 2014
- Accepted August 14, 2014
- Published online January 1, 2015.
- Sanjeev U. Nair, MBBS, MD,
- Nainesh C. Patel, MD and
- David A. Cox, MD∗ ()
- Division of Cardiology, Lehigh Valley Health Network/ University of South Florida College of Medicine, Allentown, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. David A. Cox, Lehigh Valley Health Network/University of South Florida College of Medicine, 1250 South Cedar Crest Boulevard, Allentown, Pennsylvania 18103.
Pseudoaneurysm of internal mammary arteries may be asymptomatic or present within weeks following a sternotomy procedure with features such as chest swelling, atypical chest pain, and angina or rarely with rupture and exsanguination (1,2,3).
A 62-year-old man status post-coronary artery bypass grafting and aortic mechanical valve replacement presented a decade later with angina and dyspnea. He was found to have a partially thrombosed aortic prosthetic valve. The patient underwent a reoperation with aortic bioprosthetic valve replacement. Two weeks later, the patient was readmitted with acute chest pain and ST-T changes on the electrocardiogram. Urgent coronary angiography showed the previously placed coronary artery grafts to be patent. However, there was a large (1 cm × 1 cm) pseudoaneurysm of the left internal mammary artery (LIMA) graft with leakage of contrast into the mediastinum at the site of the pseudoaneurysm suggesting an associated rupture (Figure 1, Online Video 1). Utilizing the femoral arterial approach, a 7-F LIMA guide was used to wire the LIMA, and a 3.0 × 26-mm covered Jostent stent graft (Jomed International AB, Helsingborg, Sweden) was placed and inflated to 19 atm. This completely sealed the ruptured pseudoaneurysm, and post-dilation was done with a 3.0 Quantum balloon to 20 atm (Figure 2, Online Video 2). An excellent result was obtained, with Thrombolysis In Myocardial Infarction flow grade III distally. There was good flow down to the left anterior descending coronary artery (LAD) with some evidence of wire spasm, which improved with intracoronary nitroglycerine. The LAD diagonal, as well as the collaterals to the right coronary artery, was patent. Multiple angiographic views were taken that showed no evidence of further extravasation of contrast (Figure 3, Online Video 3). The patient was eventually discharged home on dual antiplatelet therapy (aspirin and clopidogrel).
Thus, a ruptured pseudoaneurysm of an internal mammary graft can be successfully and safely repaired percutaneously using a covered stent and avoids the risks and complications associated with sternotomy.
For supplemental videos, please see the online version of this article.
Dr. Patel is on the advisory board of St. Jude Medical. Dr. Cox is on the advisory boards of Abbott Vascular, Boston Scientific, and The Medicines Company. Dr. Nair has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received August 11, 2014.
- Accepted August 14, 2014.
- American College of Cardiology Foundation