Vol 81, No 11 (2023)
Clinical vignette
Published online: 2023-09-15

open access

Page views 403
Article views/downloads 251
Get Citation

Connect on Social Media

Connect on Social Media

Giant mycotic aneurysms of the coronary artery after stent implantation for myocardial infarction due to infective endocarditis

Krzysztof Ściborski1, Marzena Stopyra-Początek1, Andrzej Szczepański1, Michał Furdal1, Paweł Gać23, Mirosław Pieróg1, Artur Telichowski1, Waldemar Banasiak1
Pubmed: 37718586
Kardiol Pol 2023;81(11):1163-1164.

Abstract

Not available

Clinical vignette

Giant mycotic aneurysms of the coronary artery after stent implantation for myocardial infarction due to infective endocarditis

Krzysztof Ściborski¹Marzena Stopyra-Początek¹Andrzej Szczepański¹Michał Furdal¹Paweł Gać²³Mirosław Pieróg¹Artur Telichowski¹Waldemar Banasiak¹
1Department of Cardiology, Center for Heart Disease, 4th Military Hospital, Wrocław, Poland
2Center for Diagnostic Imaging, 4th Military Hospital, Wrocław, Poland
3Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, Wrocław, Poland

Correspondence to:

Krzysztof Ściborski, MD, PhD,

Department of Cardiology,

4th Military Hospital,

Weigla 5, 50–981 Wrocław, Poland,

phone: + 48 261 660 452,

e-mail: k.sciborski@op.pl

Copyright by the Author(s), 2023

DOI: 10.33963/v.kp.97209

Received: April 17, 2023

Accepted: August 28, 2023

Early publication date: September 15, 2023

A 40-year-old man admitted to our department with anterior ST-segment elevation myocardial infarction (Supplementary material, Video S1). He underwent emergency primary percutaneous coronary angioplasty of the left anterior descending artery (LAD) with implantation of 2 drug-eluting stents (Supplementary material, Video S2). The patient had no cardiovascular risk factors. Intravascular imaging was not performed because of hypotension and early pulmonary edema.

During hospitalization, the patient was diagnosed with infective endocarditis caused by Streptococcus salivarius and received antibiotic treatment. He also underwent mitral valve replacement for severe mitral regurgitation with vegetation and splenectomy for splenic infarction. Echocardiography, at 12 months, revealed an additional chamber without communication with the cardiac chambers (Figure 1A, Supplementary material, Video S3) and reduced left ventricular ejection fraction with apical akinesis (30% vs. 39% on previous examination).

The patient reported no angina or heart failure symptoms, and there were no clinical or laboratory signs of inflammation. Coronary angiography showed 2 giant aneurysms (46 × 32 mm and 23 × 20 mm) at the site of stent implantation, with a slow blood flow into the LAD (Figure 1B; Supplementary material, Video S4). The shape and neck of the aneurysms were assessed by computed tomography (Figure 1C).

Figure 1. A. An additional chamber on echocardiography (white arrow). B. Aneurysms of the left anterior descending artery (LAD) on angiography (white arrows). C. Aneurysms of the LAD on computed tomography (white arrows). D. Aneurysms on intravascular ultrasound (a floating stent in the aneurysm, connection between the vessel and the stent walls white arrow). E. The LAD after the covered stent procedure (the first aneurysm with the remaining contrast material white arrow; the second aneurysm not visible black arrow). F. Follow-up computed tomography at 3 months, after the covered stent procedure; no signs of the additional chamber (white arrow)

It showed the fusiform morphology of aneurysms covering a segment of previously implanted stents, with only a narrow connection along most of the length between the vessel wall and the stents.

Because of the anatomy of the aneurysms and previous stent implantation, the patient was considered ineligible for another cardiac surgery. Although there are currently no recommendations for the management of giant coronary artery aneurysms, we chose interventional treatment owing to the potential risk of complications [1]. While there are no covered stents specifically designed for the treatment of coronary aneurysms, we decided to apply PK Papyrus stents (Biotronik AG, Bülach, Switzerland) off-label use. Intravascular ultrasound (IVUS) confirmed a fragmented connection between the stent and the vessel walls, resembling an underwater pipeline fully anchored only at the distal end (Figure 1D; Supplementary material, Video S5). Once the landing zones were determined by IVUS, 2 covered stents (3.5 × 26 mm) were implanted and postdilated with a noncompliance balloon (4.5 × 12 mm). Under IVUS guidance, another drug-eluting stent (4.5 × 12 mm) and a noncompliance balloon (5 × 12 mm) were used for additional sealing at the neck of the proximal aneurysm because of malapposition of the covered stent (Supplementary material, Video S6, Video S7), which improved blood flow into the LAD (Figure 1E; Supplementary material, Video S8). Computed tomography, at 3 months, demonstrated embolization of the aneurysm and its reduced size (Figure 1F). Echocardiography showed no additional chamber (Supplementary material, Video S9).

Mycotic coronary aneurysms are rare, especially those caused by stent implantation for ST-segment elevation myocardial infarction if an inflammatory etiology is not suspected. Nevertheless, 80% of the 100 reported cases were linked to stent implantation [2, 3]. While coronary aneurysms may be asymptomatic, some patients (especially those with giant aneurysms) may present with hemodynamic abnormalities due to the turbulence and slowing of the blood flow (as in our case). Giant aneurysms may also cause various types of ischemic heart disease such as effort angina or acute coronary syndrome. Thrombosis in the lumen of large aneurysms may lead to distal embolization and myocardial infarction, and massive enlargement can result in the compression of adjacent structures [4]. Aneurysm rupture can lead to acute cardiac tamponade [4]. Treatment options for giant aneurysms include a conservative approach, cardiac surgery (aneurysm ligation, resection, bypass grafting), and percutaneous interventions (covered stent, coil, stent-assisted coiling). The strategy depends on the patient’s condition (ongoing vs. previous inflammation) and aneurysm anatomy [1–5].

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, which allows downloading and sharing articles with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

REFERENCES

  1. Janus M, Iwańczyk S, Stanisławska K, et al. Endovascular closure of coronary artery to pulmonary artery fistula with giant aneurysm. Kardiol Pol. 2022; 80(5): 621622, doi: 10.33963/KP.a2022.0103, indexed in Pubmed: 35442511.
  2. Baker DW, Whitehead NJ, Barlow M. Mycotic coronary aneurysms. Heart Lung Circ. 2020; 29(1): 128136, doi: 10.1016/j.hlc.2018.12.004, indexed in Pubmed: 30686642.
  3. McNamara NJ, Plunkett BT. Management of a mycotic right coronary artery aneurysm with contained rupture. JACC Case Rep. 2022; 4(11): 694698, doi: 10.1016/j.jaccas.2022.03.018, indexed in Pubmed: 35677799.
  4. Kawsara A, Núñez Gil IJ, Alqahtani F, et al. Management of Coronary Artery Aneurysms. JACC Cardiovasc Interv. 2018; 11(13): 12111223, doi: 10.1016/j.jcin.2018.02.041, indexed in Pubmed: 29976357.
  5. Pham V, de Hemptinne Q, Grinda JM, et al. Giant coronary aneurysms, from diagnosis to treatment: A literature review. Arch Cardiovasc Dis. 2020; 113(1): 5969, doi: 10.1016/j.acvd.2019.10.008, indexed in Pubmed: 31866173.