Surgical management of a left anterior descending Coronary Artery Aneurysm after drug eluting stent implantation

Abstract

https://doi.org/10.1016/j.ijcha.2021.100793 2352-9067/ 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecomm Coronary artery aneurysm (CAA) formation after percutaneous coronary intervention (PCI) is a rare complication with an incidence of 0.3–6.0% [1]. Most of them are pseudoaneurysms rather than true aneurysms. The clinical presentation of these aneurysms is widely variable as some patients are asymptomatic, but some have complaints of angina or present with acute coronary syndrome (ACS) [2,3]. Herein, we report a rare case of CAA developed after PCI with a drug eluting stent (DES) who presented with ACS. A 38-year-old man with a past history of anterior wall myocardial infarction for which stenting of the left anterior descending (LAD) artery with a Promus Element (Boston scientific, USA) stent 3 28 mm at 12 atm with post dilatation at 20 atm using a noncompliant balloon (Fig. 1A/B) presented with ACS 10 months later after stenting. Coronary angiography showed an aneurysm extending to the left main coronary artery at the site of previous stent deployment (Fig. 2A/B). Because aneurysm developed in a previously stented segment with a significant involvement of the left main coronary artery, we decided to perform surgery. The patient underwent on-pump coronary artery bypass surgery with a left internal mammarian artery graft to the proximal LAD artery and a saphenous vein graft to the left circumflex artery. The aneurysm was proximally ligated and plicated (Fig. 2C). The postoperative course was uneventful and he was discharged 11 days after the operation. CAA is defined as dilatation of the coronary artery at least 1.5times the adjacent reference diameter of normal vessel segments on angiography. The exact mechanisms responsible for aneursym formation are not fully understood. Coronary aneurysm formation after stenting can be associated with high pressure inflations, residual microdissection, deep arterial wall injury, coronary stent infection and hypersensitivity reactions to the drug or polymer [2]. The other mechanisms include incomplete healing secondary to the antiproliferative action of the eluted drug and inflammatory changes of the medial arterial wall. Incomplete endothelialisation, which has not been reported after bare metal stent implantation, may have a causative role in aneurysm formation after DES placement as shown in autopsy studies [1,3]. In our case, aneurysm