Giant Stent-Related Coronary Pseudoaneurysm

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00236. Epub August 9, 2024.

A 64-year-old woman who underwent percutaneous coronary intervention (PCI) to the proximal left anterior descending artery (LAD) 2 months prior presented to the emergency room with non-ST segment elevation myocardial infarction. Transthoracic echocardiogram (TTE) showed hypokinetic anterior wall territory with moderate left ventricular (LV) dysfunction, and a cavity abutting the basal anterolateral wall of the LV (Figure A and B [*], Video 1). She had undergone computerized tomographic coronary angiography (CTCA; Figure C) a few days prior to admission, which revealed a large pseudoaneurysm sac in relation to the proximal LAD stent with no flow in the distal segment (arrows).

Due to haemodynamic compromise and angina, an intra-aortic balloon pump was inserted, and the patient was immediately taken up for coronary angiogram, which revealed an occluded LAD stent and showed the dye extravasating into a giant pseudoaneurysm adjacent to the stented coronary segment (Figure D [white arrows], Video 2). After discussion with the cardiovascular thoracic surgical team, the percutaneous exclusion of the pseudoaneurysm was deemed appropriate due to her clinical scenario. After informed consent, she underwent successful PCI by using 2 overlapping GraftMaster covered stents (Abbot): 3 x 15 mm (distal) and 3 x 15 mm (proximal) across the pseudoaneurysm. The final angiogram revealed the complete exclusion of the pseudoaneurysm, with thrombolysis in myocardial infarction-3 flow in the LAD (Figure E, Video 3). The patient had an uneventful hospital course and was discharged after 5 days on dual antiplatelet drugs. At the 3-month follow-up, repeat CTCA revealed a completely thrombosed pseudoaneurysm sac with regression in size and a patent LAD stent. The patient was doing fine at the 6-month follow-up.

Post-PCI coronary pseudoaneurysm is a rare complication, usually occurring 1 week after stent implantation, but can occur years after the procedure. The possible pathophysiological mechanisms include infection, local inflammatory reaction, polymer hypersensitivity, and acute vessel wall injury. Due to lack of standard guidelines, the management is usually case-based, and the options include either covered-stent implantation or surgical bypass in limited cases.

Affiliations and Disclosures

Suraj Kumar, MD, DM¹; Rajiv Kumar, MS, MCh²; Tejinder Singh Malhi, MD, DM¹; Bhupinder Singh, MD, DM¹

From the ¹Department of Cardiology, All India Institute of Medical Sciences, Bathinda, Punjab, India; ²Department of Cardiothoracic Vascular Surgery, All India Institute of Medical Sciences, Bathinda, Punjab, India.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Bhupinder Singh, MD, DM, All India Institute of Medical Sciences, Bathinda 151001, Punjab, India. Email:  dr_bhupinders@yahoo.in