Mr. MR

A 66 year-old male with a background of hypertension, hyperlipidemia and smoking has a history of ischemic heart disease. He previously had an acute myocardial infarction in 2013 for which he underwent drug eluting stent placement in his left anterior descending artery (LAD) and left circumflex artery (LCx) respectively. There was a large coronary artery aneurysm in the LAD and he was started on warfarin. He presented in 2019 with a Non-ST elevation myocardial infarction.
Pre PCI LAD 2013.mp4
Post PCI LAD 2013.mp4

An echocardiogram showed a left ventricular ejection fraction of 50% with regional wall motion abnormality seen in the inferior walls. Laboratory investigations showed mildly impaired renal function and a normal full blood count. Warfarin was stopped and patient was started on aspirin and plavix in preparation for the coronary angiogram. 

The coronary angiogram performed showed patent stents in the LAD and LCx. There was a de novo high grade lesion in the distal right coronary artery (RCA) and the LAD coronary artery aneurysm had increased in size from 1.4 cm to 2.2 cm. A heart team discussion was done and decision was made to perform percutaneous coronary intervention (PCI) to the RCA and for covered stent closure of the giant saccular coronary aneurysm in the LAD. The patient had declined any surgical discussion.
Pre PCI RCA 2019.mp4
Post PCI RCA 2019.mp4
Pre PCI LAD.mp4

Initial vascular access was obtained by inserting a 6 Fr slender sheath into the left radial artery. The right coronary ostium was cannulated with a 6 Fr JR 4 guide catheter. A Sion Blue guidewire was used to cross the lesion which was subsequently predilated with a 2.5 x 15 mm Ikazuchi balloon. This facilitated the passage of the Dragonfly Optis catheter and the fibrocalcific lesion was prepared with a 4.0 x 13 mm Lacrosse balloon. The lesion was then stented with a 5.0 x 24 mm drug eluting stent with optical coherence tomography (OCT) guidance. Post dilation was done with a 5.5 x 15 mm NC Emerge balloon. 
The left coronary ostium was cannulated with a 6 Fr EBU 4.0 guide catheter. The Sion Blue guidewire was used to advance into the distal LAD. OCT was performed to clarify the fistula opening, size and position. This demonstrated a single feeding fistula into the aneurysm with a 2.8 mm opening just proximal to the previous stent. Utilizing a Crusade double lumen microcatheter, a Runthrough Hypercoat guidewire was used to cross into the aneurysm to facilitate accurate placement of the covered stent. A 4.5 x 15 mm PK Papyrus covered stent was deployed across the mouth of the fistula and this was post dilated with a 5.0 x 6 mm Accuforce balloon to 18 atmospheres. Final OCT run demonstrated satisfactory stent expansion and apposition and sealing of the feeding fistula to the LAD coronary aneurysm. Angiogram demonstrated brisk TIMI III flow in the LAD once the aneurysm was sealed.

This case report showcases the effective treatment of a giant saccular coronary artery aneurysm by a covered stent. OCT can guide the precise deployment of the appropriately sized stent and optimize the PCI result by ensuring that the stent is well apposed and expanded. At 18 month review, the patient remains well with no reported symptoms. He had other coronary artery to pulmonary artery fistulas which were treated conservatively. Covered stent treatment is a viable alternative for patients with coronary aneurysms who declined surgery.