OCT Imaging of Coronary Aneurysm Around Drug-Eluting Stent
A 69-year-old woman presented with 1-week history of chest tightness associated with worsening dyspnea on exertion. She had presented with myocardial infarction 6 months earlier, requiring placement of a single 4 x 24 mm SYNERGY (Boston Scientific; Marlborough, MA) drug-eluting stent in the mid left anterior descending (LAD), and subsequent optical coherence tomography (OCT) imaging demonstrating adequate stent expansion and apposition. Electrocardiogram on latest presentation revealed T wave changes in anterolateral leads, and cardiac biomarkers were noted to be significantly elevated.
Coronary angiography revealed a large LAD and patent mid stent with native coronary ectasia and saccular aneurysm formation around the stented segment. OCT imaging confirmed adequate apposition of the stent at the distal and proximal segments (arrows) with significant ectasia and malapposition in the aneurysmal mid segment of the vessel (asterisk) around the stent (arrowhead). These findings were discussed with the patient along with cardiothoracic surgery upon patient recovery, and treatment options were deliberated, including surgical ligation of LAD with coronary artery bypass grafting to LAD and diagonal branches versus a percutaneous approach with covered stent placement in the mid LAD to exclude the aneurysm versus a conservative medical therapy approach.
She was subsequently brought back for percutaneous intervention of her aneurysmal segment. Using previous measurements from the diagnostic OCT imaging of the aneurysm, a Jomed GRAFTMASTER (Abbott Vascular; Santa Clara, CA), 4.5 x 19 mm balloon expandable covered stent was deployed within the aneurysmal segment of the stented mid LAD and post-dilated using an NC QUANTUM APEX (Boston Scientific; Marlborough, MA) 4.5 x 12 mm balloon with good expansion. Repeat OCT imaging of the stented segment confirmed adequate stent expansion and apposition in the proximal and distal aspects of the stent with minimal flow into the aneurysm.
Post-operative course was uneventful, and she was discharged on aspirin, clopidogrel, and warfarin along with her previous medications.
Date: August 13, 2018
Source: ACC Media File
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Diagnostic Imaging, Coronary Aneurysm, Drug-Eluting Stents, Stents, Coronary Angiography, Angiography