Very Late Mycotic Pseudoaneurysm Associated With Drug-Eluting Stent Fracture

Abstract

A 72-year-old woman with diabetes mellitus and endstage ischemic heart disease was admitted to the hospital because of an episode of unstable angina. She had undergone coronary artery bypass graft surgery 4 years earlier with sequential left internal mammary artery to left anterior descending and diagonal artery, and saphenous vein graft to left marginal artery. Seven months after surgery, because of disease progression, she underwent a percutaneous coronary intervention with rotational atherectomy and a 3.5ϫ32 mm paclitaxel-eluting stent implantation at the right coronary artery. During the following years, the patient had several admissions for unstable angina. A new angiography showed a diffusely diseased native vessel, an occluded saphenous graft to the marginal, a patent sequential left internal mammary artery graft to left anterior descending and diagonal artery, and persistence of the good result of the stent implanted in the right coronary artery. Because of the extension and severity of the coronary artery disease, she had been considered a no-option patient.During the present admission (1-year after the last angiography) she experienced fever and superficial phlebitis secondary to peripheral venous catheter that was treated with cloxacillin for 10 days. Five weeks later she was readmitted for persistent fever. The results of the physical examination were unremarkable, but laboratory evaluation showed leukocytosis and blood cultures positive for Staphylococcus aureus. Treatment with cloxacillin and gentamicin was initiated. Transthoracic echocardiography ruled out valvular vegetations but showed a mass in the atrioventricular groove ( Figure 1A). Magnetic cardioresonance confirmed the presence of a mass ( Figure 1B), considered in the initial differential diagnosis a cardiac tumor, such as an angiosarcoma. A whole-body 18 F-fluorodeoxyglucose positron emission tomography/ computed tomography study was performed to evaluate the cardiac mass and stage the suspected oncological disease. 18 F-fluorodeoxyglucose positron emission tomography/ computed tomography showed greatly increased glucose metabolism in the periphery of the cardiac mass ( Figure 2A and 2B), with no other findings in the rest of the body. Finally, multidetector computed tomography ( Figure 2C and 2D) provided the diagnosis: a giant pseudoaneurysm associated with stent fracture at the right coronary artery

Coronary Artery Rupture Caused by Stent Infection

“…2 These cases of stent infection share similar clinical features: fever usually accompanied with an episode of chest pain. 4 Diagnosis of stent infection can be challenging.…”

“…The first coronary stent infection was described in 1993, 1 and since then, <30 cases have been reported. 2 Most cases describe early infection, with onset between 2 days and 4 weeks after percutaneous coronary intervention.…”

Coronary Artery Aneurysm Caused by a Stent Fracture

“…There are only 20 available English-language case reports on CAA with SF [3][4][5][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] (Table). In these case reports, the patient ages ranged from 7 to 73 years (mean, 59.9 years), and 15 males and 4 females were included; there was one case where the patient's age and gender were not specified.…”

“…However, a CAA caused by an SF is most likely formed from disrupted vessel layers, i.e., a pseudo-aneurysm, and thus has a higher risk of rupture. 3,5,25,[27][28][29]31,35) Antiplatelet or antithrombotic therapies can reduce thrombosis and distal embolization but cannot reduce the risk of rupture; therefore, aneurysm repair procedures are recommended. PCI, including coil embolization, covered-stent implantation, and CABG along with additional procedures are used.…”

Infections of Intravascular Bare Metal Stents: A Case Report and Review of Literature

“…4 This fact is underlined by the remarkable increase of reported infected coronary stents in the last decade: from the 24 coronary stent infection cases reported since 2003, 16 cases were with drug eluting stents (Tables 1 and 3). 43e 45,53,54,56,57,59,61,62,67e69,72,73 The drugs eluded by the stent were rapamycine, 43 sirolimus, 45,53,56,57,61,69 paclitaxel, 44,53,54,59,72 and everolimus. 68 The local inflammation, which leads to neointimal growth (caused by proliferation of smooth muscle cells), neointimal hyperplasia, and eventually restenosis, is inhibited by the immunosuppressive effects of the drugs.…”