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| CASE REPORT |
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| Year : 2017 | Volume
: 14
| Issue : 2 | Page : 115-118 |
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A rare case of left ventricular pseudoaneurysm following stent thrombosis
Sandip Ghosh, Biswajit Majumder, KN Sudeep, Praveen Shukla
Department of Cardiology, R. G. Kar Medical College, Kolkata, West Bengal, India
| Date of Web Publication | 26-Oct-2017 |
Correspondence Address:
Sandip Ghosh
Department of Cardiology, R. G. Kar Medical College, 1, Khudiram Bose Sarani, Shyambazar, Kolkata - 700 004, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njc.njc_1_17
In the era of percutaneous coronary interventions, stent thrombosis is a rare, but potentially catastrophic complication with the majority of patients presenting with acute coronary syndromes or life-threatening arrhythmias. However, development of pseudoaneurysm following stent thrombosis is extremely rare. We report a case of left ventricular pseudoaneurysm following stent thrombosis that was successfully managed with coronary artery bypass grafting with resection of the pseudoaneurysm. Keywords: Angioplasty, left ventricular pseudoaneurysm, stent thrombosis
How to cite this article:
Ghosh S, Majumder B, Sudeep K N, Shukla P. A rare case of left ventricular pseudoaneurysm following stent thrombosis. Nig J Cardiol 2017;14:115-8 |
| Introduction | |  |
Coronary artery stents, particularly drug-eluting stents (DES), are used in the majority of patients who undergo percutaneous coronary intervention (PCI) to improve symptoms in patients with obstructive coronary artery disease. Stent thrombosis is an uncommon but serious complication of PCI with stenting. Most patients present with an acute coronary syndrome, usually with ST-segment elevation on the electrocardiogram (ECG). Its cause is total or subtotal thrombotic occlusion of a coronary artery by thrombus that originates in or close to an intracoronary stent. The cumulative incidence of stent thrombosis with bare-metal stent at 1 year was approximately 1.1% and of DES 0.7%.[1],[2] In a report from the United States CathPCI registry, among almost 7100 cases of stent thrombosis identified during a 16-month period, approximately 60% presented with ST-elevation myocardial infarction (STEMI), 23% with non-STEMI, and 17% with unstable angina.[3]
We hereby report a case of stent thrombosis following percutaneous transluminal coronary angioplasty (PTCA) for stable ischemic heart disease who developed acute STEMI with the formation of left ventricular (LV) pseudoaneurysm that was successfully managed with coronary artery bypass grafting with resection of pseudoaneurysm.
| Case Report | | |
A 63-year-old nondiabetic, hypertensive gentleman on regular follow-up to the outpatient department of our hospital complained of exertional chest pain for the past 5 months despite being on optimal medical therapy with maximally tolerated dose of antianginal therapy including β-blockers, nitrates, nicorandil, and ranolazine. He was a smoker who quit smoking 3 months back. His complete blood count was normal as was his biochemical parameters except high-density lipoprotein levels which were 36 mg/dl. His ECG was unremarkable, and echocardiography revealed no regional wall motion abnormality and an ejection fraction of 65%.
A treadmill test was performed which came out to be positive. Coronary angiography (CAG) was then performed which revealed triple vessel disease with significant stenoses involving the mid-left anterior descending (LAD), the major obtuse marginal (OM), distal left circumflex, and the distal right coronary artery (RCA) [Figure 1]a,[Figure 1]b,[Figure 1]c, and complete revascularization was performed by PTCA with DES in the said vessels [Figure 1]d,[Figure 1]e,[Figure 1]f. Following revascularization, the patient became symptom-free, and he was discharged with guideline-directed medical therapy. | Figure 1: Coronary angiography of the patient showing a significant disease in mid-left anterior descending (a) major obtuse marginal and distal circumflex (b) and distal right coronary artery (c) percutaneous transluminal coronary angioplasty and stenting was performed in the lesion in left anterior descending (d) Major obtuse marginal (e) and distal right coronary artery (f) coronary angiography was performed 2 months postpercutaneous transluminal coronary angioplasty showing in stent thrombosis in the stents in left anterior descending (g) Major obtuse marginal (h) and the patent stent in distal right coronary artery (i)
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Two months following PTCA, the patient developed severe substernal crushing chest pain. The ECG revealed ST elevation in anterior leads, troponin T was positive, and echocardiography revealed hypokinesia of anterior wall and anterior septum with an ejection fraction of 40%. There was pericardial effusion, anteriorly being 12 mm and posteriorly 18 mm without any features of tamponade. There was a suspicion of rent in the lateral wall of the left ventricle with communication into the pericardial space and pseudoaneurysm formation [Figure 2]. CAG revealed in-stent thrombosis in the stents deployed in LAD and major OM. The stent in distal RCA was patent [Figure 1]g,[Figure 1]h,[Figure 1]i. | Figure 2: Transthoracic echocardiography showing the rent (white arrow) in the lateral wall of left ventricle with communication into the pericardial space and pseudoaneurysm formation
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A cardiac computed tomography (CT) showed a large (95 mm × 45 mm) pseudoaneurysm within the epicardial fat plane with its neck at the distal end of OM1 stent. A large area of myocardial scarring and marked thinning over the lower anterior, anteroseptal, and apical region with dilated left ventricle was noted due to myocardial infarction (MI) [Figure 3]. Computed tomography angiography done during Cardiac CT also showed in-stent thrombosis of the stents deployed in LAD [Figure 4] and OM1 [Figure 5] and the patent stent in RCA [Figure 6]. | Figure 3: Cardiac computed tomography showing the pseudoaneurysm (*) within the epicardial fat plane
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 | Figure 4: Computed tomography angiography of mid-left anterior descending taken during cardiac computed tomography showing in-stent thrombosis in mid LAD and OM1
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 | Figure 5: Computed tomography angiography of major obtuse marginal and mid-left anterior descending taken during cardiac computed tomography showing in-stent thrombosis of OM1
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 | Figure 6: Computed tomography angiography of right coronary artery taken during cardiac computed tomography showing the patent stent in distal RCA
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The patient was referred to the cardiothoracic department where coronary artery bypass grafting to LAD and major OM was performed along with resection of the pseudoaneurysm. Following the operation, the patient is doing well and is now on regular follow-up.
| Discussion | | |
Formed when myocardial rupture is contained by pericardial adhesions and thrombus formation, LV pseudoaneurysms tend to rupture, with catastrophic complications. Inferior wall pseudoaneurysms that develop soon after primary percutaneous intervention and coronary artery bypass grafting for acute MI are rare.[4] In a literature review of 253 patients with a pseudoaneurysm in whom the cause was reported, 55% were related to MI, particularly of the inferior wall, which was twice as common as anterior infarction, followed by surgery (33%), most common being mitral valve replacement and aneurysmectomy itself. Trauma accounted for 7% of cases.[5] The site of pseudoaneurysm varies with etiology. Pseudoaneurysms were primarily seen in the inferior or posterolateral wall after inferior infarction, in the right ventricular outflow tract after congenital heart surgery, in the posterior subannular region of the mitral valve after mitral valve replacement, and in the subaortic region after aortic valve replacement.[6] However, LV pseudoaneurysms following stent thrombosis are extremely rare and probably not reported in literature. Diagnosis is usually made with echocardiography, cardiac CT, or cardiac magnetic resonance imaging.
Untreated pseudoaneurysms have a 30%–45% risk of rupture, and with medical therapy, the mortality approaches almost 50%.[5] With present day techniques, the perioperative mortality is <10%; the most at risk being those with severe mitral regurgitation requiring concomitant mitral valve replacement.[7]
| Conclusion | | |
Stent thrombosis usually presents with acute coronary syndrome-like presentation or fatal arrhythmias, but formation of pseudoaneurysm is extremely rare. Our case is unique because LV pseudoaneurysm formation following stent thrombosis is extremely rare and probably not reported in literature. The following case report highlights the development of this potentially catastrophic complication following stent thrombosis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Armstrong EJ, Feldman DN, Wang TY, Kaltenbach LA, Yeo KK, Wong SC, et al. Clinical presentation, management, and outcomes of angiographically documented early, late, and very late stent thrombosis. JACC Cardiovasc Interv 2012;5:131-40. [ PUBMED] |
| 4. | Choi JB, Choi SH, Oh SK, Kim NH. Left ventricular pseudoaneurysm after coronary artery bypass and valve replacement for post-infarction mitral regurgitation. Tex Heart Inst J 2006;33:505-7. [ PUBMED] |
| 5. | Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557-61. [ PUBMED] |
| 6. | Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998;128:299-305. [ PUBMED] |
| 7. | Bolooki H. Surgical treatment of complications of acute myocardial infarction. JAMA 1990;263:1237-40. [ PUBMED] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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