Abstract
We present a case of a ruptured mycotic coronary aneurysm effectively treated with covered stents and phased surgery. The covered stent, however, became occluded two years later. Because of the low invasiveness, a covered stent treatment may be advantageous over conventional surgery but trade off long-term vascular patency.
Learning objective
To recognize the presence of a ruptured infectious coronary aneurysm after a primary coronary stenting for ST-elevation myocardial infarction.
To discuss the treatment strategies for a ruptured infectious coronary aneurysm with a covered stent.
Keywords: Mycotic coronary aneurysm, Covered stents, Phased surgery, Percutaneous coronary intervention
Introduction
Mycotic coronary aneurysm is a rare complication in patients after percutaneous coronary intervention (PCI) [1]. Furthermore, rupture of coronary artery aneurysm, also rare, is life-threatening.
Case report
A 72-year-old man was referred to our emergency department with chest discomfort that had been persistent for 4 h. His medical history included hypertension, hyperlipidemia, hyperuricemia, and a previous subarachnoid hemorrhage/meningitis treated with a ventriculoperitoneal shunt. He was a smoker in the past and had no family history of other diseases.
His blood pressure was 123/59 mmHg; heart rate on admission, 89 beats per minute; and oxygen saturation, 99 % on room air. A physical examination showed substantial chest discomfort without additional heart sounds on auscultation and pulmonary rales. The ST-segment in leads V2–V5 was raised on an electrocardiogram, and an echocardiography revealed anterior wall hypokinesis. Emergency coronary angiography revealed proximal left anterior descending artery occlusion with a thrombus; therefore, primary PCI was performed with drug-eluting stents (Fig. 1).
Fig. 1.
Coronary angiography on admission with acute myocardial infarction before (A) and after (B) revascularization.
Fever and hypotension were reported one week after treatment, as well as chest discomfort, broad ST elevation, and pericardial effusion. A pericardiocentesis was performed, obtaining 250 ml of sanguineous fluid. As a result, the patient was diagnosed with purulent pericarditis and was given intravenous ampicillin-sulbactam. Blood and pericardial fluid cultures were reported to contain methicillin-susceptible Staphylococcus aureus.
The patient's hemodynamic condition and inflammation improved after treatment, but he developed severe chest discomfort and hypotension on Day 22 of hospitalization. An echocardiography revealed a re-elevated pericardial effusion, and contrast-enhanced computed tomography identified a ruptured mycotic coronary aneurysm (MCA) in the left anterior descending artery with hemorrhagic pericardial effusion (Fig. 2, Video 1).
Fig. 2.
Contrast-enhanced computed tomography exhibited a coronary aneurysm in the left anterior descending artery with hemorrhagic pericardial effusion.
Due to his severely unstable hemodynamics, a PCI was performed for lowering the treatment invasiveness, and three polytetrafluoroethylene-covered stents were implanted (2.75 × 16 mm, 3.5 × 16 mm, and 3.5 × 16 mm; Abbott Vascular, Redwood, CA, USA) (Fig. 3, Video 2, Video 3). The day following the PCI, a staged surgical treatment with aneurysm resection, debridement, and omental flap transposition was undertaken. The surgical pathology report of the coronary aneurysm showed that the wall did not exhibit an arterial structure. Although neutrophil infiltration was conspicuous in some segments, no bacteria were detected in the specimen.
Fig. 3.
Coronary angiography before (A, B) and after (C, D) percutaneous coronary intervention with covered stents for a coronary aneurysm in the left anterior descending artery.
The postoperative course was uneventful and dual antiplatelet therapy was deescalated to clopidogrel monotherapy after one year. The infection was controlled by intravenous cefazolin for 4 weeks and life-long oral doxycycline thereafter.
Two years postoperatively, a follow-up coronary angiogram revealed good patency of the covered stents. Seven months after follow-up angiography, he developed acute pancreatitis, and his antiplatelet therapy of clopidogrel was discontinued for two weeks due to the concern about the occurrence of hemorrhagic events. Following pancreatitis therapy, a follow up electrocardiogram revealed new development of Q waves and inverted T in V4–5. The covered stents were found to be occluded on a coronary angiography. He was treated conservatively with appropriate medicinal therapy because his chronic heart failure status was still compensated, and his symptoms were stable.
Discussion
MCAs are extraordinarily rare but life-threatening. Surgical excision and revascularization of the MCA is considered the standard therapy. However, a novel endovascular approach utilizing covered stents was successfully used to treat coronary artery aneurysms [2]. Baker et al. reviewed 97 MCA case reports from articles published between 1812 and 2017, indicating the occurrence of MCA is rare, and reported that 61 patients underwent surgery, 3 had PCI, and 7 had antibiotic therapy. They also observed that short-term mortality was high (42.6 %), and that patients who had undergone surgery had a death rate of 20.9 %. However, three patients who received PCI had good short-term outcomes [1]. In the present case, PCI with covered stents and surgical debridement successfully treated the ruptured MCA, and are thus regarded effective treatments; however, the risk of recurrent infection would seem to preclude them as a definitive therapeutic choice for MCA.
Conclusions
PCI with covered stent and subsequent surgical debridement for a ruptured infectious coronary aneurysm is an alternative treatment option for highly comorbid patients. Treatment with covered stent may trade off low invasiveness and long-term vessel patency as compared with surgical treatment.
The following are the supplementary data related to this article.
Contrast-enhanced computed tomography exhibited a coronary aneurysm in the left anterior descending artery with hemorrhagic pericardial effusion.
Left coronary angiogram after rupture of coronary aneurysm. Two large coronary aneurysms were observed through stents implanted at primary percutaneous coronary intervention for acute myocardial infarction.
Left coronary angiogram after covered stents implantation. Four covered stents were implanted in proximal left anterior descending coronary artery.
Funding
No financial funding was received.
Patient permission/consent statement
Permission for publication was obtained from patient.
Declaration of competing interest
Authors declare no conflict of interests.
Acknowledgments
This paper was reported in the 30th scientific meeting of the Japanese Association of Cardiovascular Intervention and Therapeutics.
Footnotes
Funding and Disclosure: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
References
- 1.Baker D.W., Whitehead N.J., Barlow M. Mycotic coronary aneurysms. Heart Lung Circ. 2020;29:128–136. doi: 10.1016/j.hlc.2018.12.004. [DOI] [PubMed] [Google Scholar]
- 2.Torii S., Ohta H., Morino Y., Nakashima M., Suzuki Y., Murata S., et al. Successful endovascular treatment of rupture of mycotic left main coronary artery aneurysm. Can J Cardiol. 2013;29(1014):e7–e9. doi: 10.1016/j.cjca.2012.11.025. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Contrast-enhanced computed tomography exhibited a coronary aneurysm in the left anterior descending artery with hemorrhagic pericardial effusion.
Left coronary angiogram after rupture of coronary aneurysm. Two large coronary aneurysms were observed through stents implanted at primary percutaneous coronary intervention for acute myocardial infarction.
Left coronary angiogram after covered stents implantation. Four covered stents were implanted in proximal left anterior descending coronary artery.