Ann Thorac Surg 2009;88:664-665. doi:10.1016/j.athoracsur.2008.11.077
© 2009 The Society of Thoracic Surgeons
Case Reports
A Fractured Sirolimus-Eluting Stent With a Coronary Aneurysm
Sung Hea Kim, MDa,
Hyun Joong Kim, MDa,
Seong Woo Han, MDa,
Sang Man Jung, MDa,
Jun Suk Kim, MDb,
Hyun Keun Chee, MDb,
Kyu Hyung Ryu, MD, PhD, FACCa,*
a Department of Cardiology, Konkuk University School of Medicine, Seoul, Korea
b Department of Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
Accepted for publication November 20, 2008.
* Address correspondence to Dr Ryu, Department of Cardiology, Konkuk University School of Medicine, 4-12 Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea (Email: khryu{at}kuh.ac.kr).
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Abstract
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A 55-year-old man had undergone successful percutaneous intervention with a sirolimus-eluting stent, placed in the right coronary artery (2.5 x 33 mm) and distal left circumflex artery (3.0 x 28 mm) without high pressure ballooning. Twelve months later he presented with unstable angina. Angiography revealed two fracture sites on the right coronary artery–deployed stent, with a large aneurysm and an aneurysmal dilatation of the left circumflex artery without stent fracture. Due to the potential risk of aneurysmal rupture, he underwent coronary artery bypass grafting and ligation of the aneurysm.
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Introduction
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Although the advent of drug-eluting stents (DES) have ushered in a remarkable advance in interventional cardiology, with a very low re-stenosis rate in randomized studies, there have been some concerns with the widespread use of DES.
Recent reports have highlighted stent fracture as a potential cause of late thrombosis and re-stenosis [1–3]. Cases involving the development of coronary artery aneurysms have been reported to be rare, but have serious complications after percutaneous coronary intervention.
We report here an unusual case of a stent fracture with a coexisting giant aneurysm that required coronary artery bypass surgery.
A 55-year-old man presented with chest pain, inferior ST elevation, and elevated cardiac markers. After coronary angiography, a critical proximal right coronary artery stenosis with an ulcerating plaque and a total occlusion of the distal left circumflex artery with a collateral from the left anterior descending artery were noted. Successful angioplasty was performed with a sirolimus-eluting stent (Cypher; Cordis, Miami Lakes, FL) placed in the right coronary artery (2.5 x 33 mm) and distal left circumflex artery (3.0 x 28 mm) without high pressure ballooning. Twelve months later, he was readmitted with newly developed resting chest pain. Right coronary angiography showed two fracture sites of the implanted stent with displacement of the free stent fragment and huge aneurysmal changes (Fig 1); left angiography revealed a coronary aneurysm in the mid-portion of the DES in the left circumflex artery.
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Fig 1. (A) Angiographic image and (B) schematic view of the right coronary artery shows a huge aneurysm (black arrows). Pre-contrast angiographic images from the (C) left anterior oblique view and the (D) right anterior oblique view reveal stent fragments (white arrow heads). (LCx = left circumflex artery.)
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Due to the potential risk of aneurysmal rupture, he underwent on-pump beating coronary artery bypass grafting with skeletonized right internal thoracic artery on the following day. Proximal and distal vessel ligations of the right coronary artery aneurysm were done, after which the fractured stent struts were withdrawn (Fig 2).
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Fig 2. Intraoperative gross finding shows (A) right coronary artery aneurysm (white arrow) and drawn segments of (B) the fractured drug-eluting stent.
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Comment
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There have been several reports of DES fractures with aneurysm formation after DES implantation [4, 5]. Only one report has shown a coexisting aneurysmal dilatation with a stent fracture, in which percutaneous coronary intervention was performed [5]. However, there are no reported cases that have required coronary artery bypass grafting.
Although the mechanism of aneurysm formation is still unclear, previous reports suggest several potential causes [1, 6–8]: (1) an excess use of an oversized balloon or high pressure ballooning, resulting in intima-media tearing; (2) a stent fracture that might break down the structure of the arterial wall mechanically; and (3) the unique property of the DES, which may bring the localized overactivated inflammation against the polymer, the inhibition of the healing process by the coated drug, or delayed hypersensitivity to the coated drug.
In this case, the simultaneous occurrence of coronary aneurysm at both the DES-implanted sites without high-pressure ballooning suggests that an aneurysmal dilatation may have preceded stent fracture, rather than the fracture of the stent leading to aneurysmal change. Thus, the unique property of the DES might be the potential cause of coronary aneurysm.
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References
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- Sianos G, Hofma S, Ligthart JM, Saia F, Hoye A, Lemos PA, Serruys PW. Stent fracture and restenosis in the drug-eluting stent era Catheter Cardiovasc Interv 2004;61:111-116.[Medline]
- Min PK, Yoon YW, Moon Kwon H. Delayed strut fracture of sirolimus-eluting stent: a significant problem or an occasional observation? Int J Cardiol 2006;106:404-406.[Medline]
- Shaikh F, Maddikunta R, Djelmami-Hani M, Solis J, Allaqaband S, Bajwa T. Stent fracture, an incidental finding or a significant marker of clinical in-stent restenosis? Catheter Cardiovasc Interv 2004;71:614-618.
- Vaknin-Assa H, Assali A, Fuchs S, Kornowski R. An unusual cluster of complications following drug-eluted stenting: stent fracture, peri-stent aneurysm and late thrombosis Isr Med Assoc J 2007;9:331-332.[Medline]
- Okamura T, Hiro T, Fujii T, et al. Late giant coronary aneurysm associated with a fracture of sirolimus eluting stent: a case report J Cardiol 2008;51:74-79.[Medline]
- Stabile E, Escolar E, Weigold G, et al. Marked malapposition and aneurysm formation after sirolimus-eluting coronary stent implantation Circulation 2004;110:e47-e48.[Free Full Text]
- Virmani R, Guagliumi G, Farb A, et al. Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent: should we be cautious? Circulation 2004;109:701-705.[Abstract/Free Full Text]
- Nebeker JR, Virmani R, Bennett CL, et al. Hypersensitivity cases associated with drug-eluting coronary stents: a review of available cases from the Research on Adverse Drug Events and Reports (RADAR) project J Am Coll Cardiol 2006;47:175-181.[Abstract/Free Full Text]
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Abstract
Introduction
