Author + information
- Received June 2, 2017
- Revision received July 6, 2017
- Accepted July 25, 2017
- Published online November 15, 2017.
- Gabriel T. Faz, MD,
- Amit Gupta, MD,
- Fabiana Rollini, MD,
- Leslie Oberst, MD,
- Patrick Antoun, MD,
- Dominick J. Angiolillo, MD, PhD and
- Theodore A. Bass, MD∗ ()
- ↵∗Address for correspondence:
Dr. Theodore A. Bass, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, Florida 32209.
A 70-year-old Caucasian man with a history of coronary artery disease (CAD) 9 months status post–2-vessel coronary artery bypass grafting (left internal mammary artery to left anterior descending artery and saphenous vein graft to the first oblique marginal artery) performed at an outside hospital was admitted with a non–ST-segment elevation myocardial infarction. He underwent coronary angiography, which showed severe native CAD and both grafts patent. The right coronary artery (RCA) had a severe stenosis in the ostium and proximal segment. Notably, the proximal RCA was characterized by an image suggestive of a perforation with flow into the epicardium leading to a contained pseudoaneurysm (Figure 1A). The patient was sent for a coronary computed tomography scan for further anatomical evaluation, which showed a sternal wire abutting a large 2.2-cm RCA epicardial pseudoaneurysm with mural thrombus (Figure 1B). This finding was likely attributed to vessel injury while suturing the sternum. The decision was to perform percutaneous coronary intervention of the RCA. Following pre-dilatation with a 3.0 mm × 12 mm compliant balloon (Abbott Vascular, Santa Clara, California) inflated up to 16 atm, 2 sequential 3.5 mm × 16 mm GraftMaster covered stents (Abbott Vascular) implanted at 18 atm were required to cover the area of perforation. Post-dilation was performed using a 4.5 mm × 20 mm noncompliant balloon (Boston Scientific, Maple Grove, Minnesota) inflated to 16 atm. Finally, a 4.0 mm × 28 mm REBEL bare-metal stent (Boston Scientific) was implanted at 18 atm extending from the site of perforation to the ostial RCA, followed by post-stent dilation using a 4.5 mm × 12 mm noncompliant balloon (Abbott Vascular) serially inflated up to 20 atm. No further leak was observed on angiography (Figure 1C). The patient was treated with aspirin and clopidogrel. Forty-eight hours after the procedure, right coronary angiography was performed, which showed a patent stent and a very small residual pseudoaneurysm (Figure 1D). The patient remained asymptomatic throughout his hospitalization. This is the first documented angiographic case showing a coronary artery tear complication during open-heart surgery followed by successful percutaneous coronary intervention repair.
Dr. Angiolillo has received consulting fees or honoraria from Amgen, AstraZeneca, Bayer, Biosensors, Chiesi, Daiichi Sankyo, Eli Lilly, Janssen, Merck, PLx Pharma, Pfizer, and Sanofi; honoraria for participation in review activities for CeloNova and St. Jude Medical; and institutional grant support from Amgen, AstraZeneca, Biosensors, CeloNova, CSL Behring, Daiichi Sankyo, Matsutani Chemical Industry Co., Merck, Novartis, and Renal Guard Solutions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 2, 2017.
- Revision received July 6, 2017.
- Accepted July 25, 2017.
- 2017 American College of Cardiology Foundation