Patch Angioplasty for a Left Main Coronary Artery Pseudoaneurysm following Percutaneous Coronary Intervention

Abstract

A coronary artery pseudoaneurysm usually occurs following catheter-based intervention, probably due to traumatic dissection or perforation of a coronary artery resulting in the disruption of the media without blood seepage through the adventitia. 1) Because of rarity of this condition, treatment strategies are not clearly defined. Herein we report a patient who presented with a left main coronary artery pseudoaneurysm. A 56-year-old woman, who had been on hemodialysis for end-stage renal disease due to chronic glomerulonephritis 5 years before, was referred to our hospital because she had a saccular aneurysm in the left main coronary artery. She had percutaneous coronary intervention (PCI) to the diagonal branch using a rotablator at the age of 54 (Fig. 1A, B). The aneurysm was diagnosed with a pseudoaneurysm by intravascular ultrasound (IVUS), the entry of which was located in the left main coronary artery just proximal to its bifurcation ( Fig. 2A, B). Then the pseudoaneurysm was indicated for surgical intervention. Preoperative contrast computed tomography showed the degree of calcification in the left main coronary artery (Fig. 3A, B). After the patient had median sternotomy and systemic heparinization made, she was placed on cardiopulmonary bypass (CPB). Retrograde cold blood cardioplegia was continuously administered for myocardial protection. The pulmonary artery was transected 2 cm proximal to its bifurcation to optimize the exposure. An aneurysm 8 mm in size was found to be located in the left main coronary artery (Fig. 4A, B). The wall of the aneurysm was incised longitudinally from the left main to the proximal left anterior descending coronary artery. The damaged arterial wall was excised and repaired with a saphenous vein patch (12×25 mm) sutured to the firm arterial wall with a 7-0 polypropylene, while the orifice of the circumflex artery was spared.There was no thrombus in the lumen. Pulmonary artery continuity was restored using a 5-0 polypropylene suture. The patient was weaned easily from CPB and her postoperative course was uneventful. The histological study of the damaged arterial wall confirmed the diagnosis of a pseudoaneurysm (Fig. 5). Postoperative contrast computed tomography showed the anastomosis site was acceptable (Fig. 6). She underwent a living renal transplantation one year postoperatively and has been doing well. II. CommentA coronary artery pseudoaneurysm is as rare a complication as a coronary artery perforation in catheter-based intervention. It is diagnosed by IVUS as a "large, thin-walled, narrow-necked, saccular, vascular structure having no normal arterial wall elements and communicating with the real arterial lumen through a rupture in the arterial wall. 1) Using IVUS, Maehara and colleagues studied 77 consecutive patients with native coronary artery aneurysms by angiography. Of these, only 27% were true aneurysms by IVUS and 4% were pseudoaneurysms. The remaining aneurysmal changes were complex plaques in 16% and Patch Angioplasty for a Left Main Coronary Artery Pseudoan...