J A C C : C A S E R E P O R T S V O L . 1 , N O . 4 , 2 0 1 9

ª 2 0 1 9 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E AM E R I C A N

C O L L E G E O F C A R D I O L O G Y F O U N DA T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R

T H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .

CASE REPORT

CLINICAL CASE

Percutaneous Treatment ofLong Coronary AneurysmsNovel Technique for Increased Efficacy and Safety

Sanjay C. Shah, MD, DM,a Tejas M. Patel, MD, DM,a Gaurav A. Patel, MD,b Samir B. Pancholy, MDb

ABSTRACT

L

�

�

ISS

Fro

Th

Inf

Ma

Although covered stents have been available for percutaneous treatment of coronary aneurysms, patients with longer

aneurysmal segments have been difficult to treat with covered stents. We describe a case of a right coronary artery

aneurysm with an angiographically estimated length exceeding 30 mm treated percutaneously using covered stents and

conventionally available hardware. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2019;1:628–32) © 2019

The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access

article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

C oronary artery aneurysms, defined as greaterthan a 1.5-fold increase in the diameter ofthe coronary lumen compared with the adja-

cent reference lumen, have been observed in 0.3% to4.9% of patients referred for coronary angiograms (1).The etiologies range from atherosclerotic degenera-tion, which is the most common etiology, to geneticdisorders as well as inflammatory conditions thatlead to coronary artery aneurysm formation.Although the natural history of these aneurysms islargely unknown, a 2- to 4-fold higher incidence ofmajor adverse cardiovascular events (2) raisesconcern in younger patients with both patient andprovider preference for mechanical exclusion ofaneurysmal segments either percutaneously orsurgically if the procedural risks are acceptable.

EARNING OBJECTIVES

To be able to treat long coronary aneurysmswith covered stents.To be able to increase the probability ofprocedural success using contemporary de-vices and techniques.

N 2666-0849

m aApex Heart Institute, Ahmedabad, India; and bThe Wright Center for G

e authors have reported that they have no relationships relevant to the c

ormed consent was obtained for this case.

nuscript received June 16, 2019; revised manuscript received October 2,

Percutaneous management has included the use ofcovered stents with or without coil embolization.Covered stents with sizes suitable for coronary usehave been available with lengths ranging from 16 to26 mm for the Graftmaster (Abbott, Abbott Park,Illinois) and the Papyrus stent (Biotronik, Berlin, Ger-many). Patients with longer aneurysmal segmentshave been difficult to treat reliably using coveredstents. Although multiple overlapping covered stentuse has been reported in 2 patients in the literature(3,4), these stents are less trackable compared withconventional stents, and hence the probability ofthe inability to cross the free-hanging proximal endof the first deployed covered stent with the secondcovered stents to create the necessary overlap andproper sealing needs to be considered, and the uncer-tainty may make the interventional operator and thepatient reconsider percutaneous options for treat-ment of longer aneurysmal segments.

We describe a case of a right coronary arteryaneurysm with an angiographically estimated lengthexceeding 30 mm treated percutaneously usingcovered stents and conventionally availablehardware.

https://doi.org/10.1016/j.jaccas.2019.10.004

raduate Medical Education, Scranton, Pennsylvania.

ontents of this paper to disclose.

2019, accepted October 9, 2019.

FIGURE 1 Coronary Angiogram Demonstrating Right

Coronary Aneurysm

A coronary angiogram showed a long segment of fusiform right

coronary artery aneurysm.

FIGURE 2 Deployment of Drug-Eluting Stent Across the

Aneurysmal Segment

A 3.0/38-mm drug-eluting stent was deployed at the proximal

to mid-right coronary artery encompassing the aneurysmal

segment, with proximal and distal landing zones in the normal

reference segments.

J A C C : C A S E R E P O R T S , V O L . 1 , N O . 4 , 2 0 1 9 Shah et al.D E C E M B E R 2 0 1 9 : 6 2 8 – 3 2 New Technique for Treatment of Long Coronary Aneurysms

629

HISTORY OF PRESENTATION

A 25-year-old woman presented to a tertiary carecenter in Ahmedabad, India, with new-onset retro-sternal chest pain. She had no coronary risk factors.The initial 12-lead electrocardiogram showed inferiorST-segment depression and T-wave inversion.Troponin T was elevated at 5.3 ng/ml (normalreference <0.04 ng/ml). She had another episode ofchest pain while at rest with dynamic inferior ST-segment depression.

PAST MEDICAL HISTORY

The patient had no past history of any medical con-ditions. She did not report any family history of an-eurysms or sudden death.

INVESTIGATIONS

Coronary angiography was performed that showed afusiform long aneurysm in the mid-right coronaryartery (Figure 1). The left main, left anteriordescending, and left circumflex arteries as well astheir branches were angiographically normal andhad normal flow. Besides the coronary tree,the cerebrovascular tree and large vessels wereimaged for the presence of aneurysms usingcomputed tomography angiograms of the chest,abdomen, and brain, and no other aneurysms weredetected.

DIFFERENTIAL DIAGNOSIS

In view of the absence of atherosclerotic risk factors,obstructive coronary artery disease, spasm, or otheretiologies, coronary embolism from the aneurysmwas felt to be the most likely explanation for theacute coronary syndrome presentation, especially inview of the concordance of the ST-segment changesin the inferior electrocardiographic leads and rightcoronary territory embolism from the right coronaryartery aneurysm. A genetic disorder leading to an-eurysms in multiple vascular sectors was a possibil-ity; hence, other circulatory beds were scanned,although no aneurysms were identified in thecerebrovascular, aortic, or viscero-peripheraldistributions.

MANAGEMENT

After an extensive discussion of several treatmentoptions with the patient including dual antiplatelettherapy and cautious monitoring with follow-upnoninvasive imaging versus exclusion of the

aneurysm either percutaneously or surgically, thepatient elected to proceed with percutaneouscoronary intervention for exclusion of theaneurysm.

FIGURE 3 Deployment of Covered Stents Across the Aneurysmal Segment

After making a metallic foundation bridging the 2 normal segments, a 3.0/26-mm and 3.0/16-mm Papyrus stents were deployed across the aneurysmal segment inside

the previously deployed drug-eluting stent.

Shah et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 4 , 2 0 1 9

New Technique for Treatment of Long Coronary Aneurysms D E C E M B E R 2 0 1 9 : 6 2 8 – 3 2

630

PROCEDURAL DETAILS

TECHNIQUE. A 6-F hydrophilic introducer sheathwas placed in the right radial artery after standardpreparation, and 6-F JR4 guide catheter was used toengage right coronary artery ostium. A 0.014-inchcoronary guidewire was placed successfully in thedistal right coronary artery after careful

FIGURE 4 Final Angiogram of the Right Coronary Artery

An angiogram of the right coronary artery after covered stents

were deployed showed total exclusion of the aneurysmal sac

with optimal stent deployment.

maneuvering. A 3.0/38-mm drug-eluting stent wasdeployed at the proximal to mid-right coronary arteryencompassing the aneurysmal segment, with prox-imal and distal landing zones in the normal referencesegments (Figure 2).

After making a metallic foundation bridging the 2normal segments across the aneurysm, a 3.0/26-mmPapyrus stent was deployed from the distal refer-ence segment projecting part way into the aneu-rysmal segment inside the previously deployeddrug-eluting stent. Another 3.0/18-mm Papyrusstent was deployed with 2 to 3 mm overlap with the

FIGURE 5 Optical Coherence Tomographic Imaging of the

Right Coronary Artery

Optical coherence tomographic imaging was performed using a

Dragonfly catheter in a standard fashion showing adequate

stent expansion.

FIGURE 6 Follow-up Coronary Angiography at the

6-Month Interval

Coronary angiography was repeated at the 6-month follow-up

with no angiographic lumen narrowing or hemodynamically

significant stenoses.

FIGURE 7 Follow-up Optical Coherence Tomography at the

6-Month Interval

Follow-up optical coherence tomography showed excellent

endothelial coverage of the stent hardware and mild thick-

ening at the overlapping segment of the Papyrus stent, likely

caused by dual hardware layer–related signature or mild

intimal hyperplasia.

J A C C : C A S E R E P O R T S , V O L . 1 , N O . 4 , 2 0 1 9 Shah et al.D E C E M B E R 2 0 1 9 : 6 2 8 – 3 2 New Technique for Treatment of Long Coronary Aneurysms

631

previous Papyrus stent in the proximal segment ofthe aneurysm, projecting into the normal referencesegment (Figure 3). The stents were post-dilated witha 3.25/15-mm noncompliant balloon to achieveadequate stent expansion (Figure 4). Optical coher-ence tomographic imaging was performed using aDragonfly catheter (Abbott Vascular Inc., RedwoodCity, California) in a standard fashion (Figure 5),indicating adequate stent expansion and optimalapposition in the nonaneurysmal edges. The electro-cardiographic changes resolved and did not recur af-ter the procedure.

DISCUSSION

Coronary artery aneurysms present a challenge from aprocedural and management standpoint, especially inyounger patients in whom in view of the lack ofclarity of the natural history, the potential risksassociated with this disease favor procedure-basedexclusion, either percutaneous or surgical.

Percutaneous exclusion of these aneurysms usingcovered stents offers a very attractive option in viewof its acute efficacy as well as procedural simplicity.One of the limitations of percutaneous exclusion ofcoronary aneurysms is the limited availability of thecovered stent lengths. Longer segments such as inthis patient pose a particular challenge because

26 mm of covered stent would not successfullyexclude the aneurysm.

Although one can try to telescope a covered stentinto a previously deployed free-hanging end ofanother covered stent, this technique has limitedreliability, especially in anatomically adverse coro-nary substrates, and the inability to advance thesecond covered stent into the first deployed coveredstent may lead to ineffective exclusion of the aneu-rysmal sac and potentially create a nidus forthrombus formation due to persistent stasis andmetallic and polytetrafluoroethylene-related hard-ware burden. Hence, creating a tubular lumentraversing the aneurysmal segment is likely to aid inprecise placement of overlapping covered stents andhence improve procedural safety. This may be ach-ieved using our described technique. Using ourtechnique, creating a metallic “bridge” across theaneurysm flanking the segment from normal prox-imal to distal reference landing zones and then usingthis metallic foundation to precisely deploy multiplecovered stents inside the conventional stent archi-tecture, can reliably exclude the aneurysm segmentutilizing the available contemporary hardware. Theother benefit of this technique, using a drug-elutingstent as a bridge, is the potential lower restenosis

Shah et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 4 , 2 0 1 9

New Technique for Treatment of Long Coronary Aneurysms D E C E M B E R 2 0 1 9 : 6 2 8 – 3 2

632

rate at the landing zones. The multilayer metalburden may increase the risk of target vessel failure.Continuing dual antiplatelet therapy for a longerduration may help mitigate the potentially higher riskof thrombotic events.

Our technique allows the interventional operatorto offer the patients with long coronary artery aneu-rysms a safe option with less uncertainty and likelyhigher procedural success, enhancing the capabilityof the percutaneous procedure to long coronary an-eurysms. The feasibility of this technique through 6-Fguide catheters makes it possible to perform theseprocedures using transradial access, furtherincreasing procedural safety and comfort.

FOLLOW-UP

Coronary angiography was repeated at the 6-monthfollow-up with no angiographic lumen narrowing orhemodynamically significant stenoses (Figure 6).Optical coherence tomography was performed with

excellent endothelial coverage of the stent hardwareand mild thickening at the overlapping segment ofthe Papyrus stent, likely caused by dual hardwarelayer–related signature or mild intimal hyperplasia(Figure 7). The geometry of the lumen was found to besymmetric.

CONCLUSIONS

Percutaneous exclusion of coronary artery aneurysmsfor the prevention of future complications could beoffered to patients with longer segments of aneu-rysms by using overlapping covered stents,improving procedural certainty by deploying a longconventional stent first and using it to create tubulararchitecture across the aneurysmal segment.

ADDRESS FOR CORRESPONDENCE: Dr. Samir B.Pancholy, The Wright Center for Graduate MedicalEducation, 401 North State Street, Clarks Summit,Pennsylvania 18411. E-mail: pancholy8@gmail.com.

RE F E RENCE S

1. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmalcoronary artery disease. Circulation 1983;67:134–8.

2. Doi T, Kataoka Y, Noguchi T, et al. Coronaryartery ectasia predicts future cardiac events inpatients with acute myocardial infarction. Arte-rioscler Thromb Vasc Biol 2017;37:2350–5.

3. Cereda AF, Tiberti G, Pera IG, et al. A giantcoronary artery aneurysm treated using multipleoverlapping covered stents. J Am Coll Cardiol Intv2017;10:e127–8.

4. Jurado-Román A, Lozano-Ruíz-Poveda F,López-Lluva MT, Sánchez-Pérez I. Reconstructionof right coronary artery with 2 giant aneurysms in

series using 3 overlapped covered stents. J AmColl Cardiol Intv 2017;10:1060–2.

KEY WORDS coronary aneurysm, newtechnique, percutaneous coronaryintervention