Percutaneous Management of a Coronary Bifurcation Aneurysm with Mesh-Covered Stents and the Simultaneous Kissing Stent Technique

Abstract

A 63-year-old man was admitted with a clinical diagnosis of acute coronary syndrome (non-ST-segment Case ReportIn 2013, a 63-year-old man, with hypertension and dyslipidemia, was admitted under a clinical diagnosis of acute coronary syndrome (non-ST-segment elevation), characterized by regional hypokinesia of the left ventricular posterior and lateral walls and by positive cardiac biomarkers. The coronary angiogram showed a large aneurysm with a mural thrombus at the bifurcation of a dominant left circumflex coronary artery (LCx) and a sizable 2nd marginal branch (OM2) (Fig. 1). Intravascular ultrasonography (IVUS) confirmed the presence of a true aneurysm: maximum diameter, 12.5 mm; total length (with transitions), 39 mm; proximal reference diameter, 5.5 mm; and distal reference diameters, 4 mm in the LCx and 4.5 in the OM2.The patient's clinical presentation with an apparent acute coronary syndrome, his negative history for Kawasaki disease (or other forms of arteritis), and the 3-layered wall pattern upon IVUS imaging, led us to speculate that the most likely pathogenesis was atherosclerotic positive remodeling with thromboembolism. A moderate hazy lesion in the proximal OM2, possibly a remnant of a stratified thrombus (Fig. 1), was supportive of that hypothesis. After discussion of the case with other members of the cardiovascular team, we excluded medical management with a vitamin K antagonist or antiplatelet agents. Because the progression and clinical consequences of a large aneurysm are unpredictable and potentially catastrophic, we instead chose percutaneous management with 2 mesh-covered stents.At the time of the intervention, the patient was already on double antiplatelet therapy (clopidogrel 75 mg and aspirin 100 mg orally). After inserting the sheaths, we administered unfractionated heparin (100 IU/kg). Two 6F extra-backup guiding catheters were then advanced through the right femoral artery and the right radial artery. After wiring both branches, we advanced-to the bifurcation-2 polyethylene terephthalate (PET) MicroNet-covered MGuard 39 × 3.5-mm stents (InspireMD,