Recurrence following percutaneous exclusion of giant coronary pseudoaneurysm: a case report.

Background: Emergence of coronary giant pseudoaneurysm (PSA) after stent implantation is potentially catastrophic and may end up with life threatening complications if not managed promptly. There is scarcity of data in existing literature with respect to guidelines on the management of coronary PSA following stent implantation. We report the recurrence of coronary PSA following initial percutaneous management of a giant coronary PSA using multiple stent grafts.

Case presentation: A 38-year-old male who underwent primary angioplasty of the right coronary artery (RCA) about a month back, presented with dull aching precordial chest pain for the last 15 days. A repeat coronary angiography revealed giant coronary PSA in proximal to mid RCA. Considering the significantly large size of the coronary PSA with symptoms of impending rupture, the giant coronary PSA was successfully excluded by implanting three sequentially coronary stent grafts. However, after one and a half months, the patient again presented with a similar kind of dull aching chest pain. We found a recurrence of coronary PSA in a segment of the coronary artery distal to the portion excluded by stent grafts. This recurrent coronary PSA was once again successfully excluded by redeploying two more stent grafts with the help of a guide extension catheter.

Conclusions: In this case, vessel wall injury as a result of aggressive post dilatation using an oversized balloon during the index procedure was the contributor to the giant coronary PSA formation. It usually appears early after the index procedure (within 4 weeks). Though the usual strategy used to exclude coronary aneurysm is by using the minimal number of stent grafts (due to the inherent increased risk of restenosis/thrombosis in stent grafts) in post angioplasty traumatic aneurysm it is prudent to exclude the entire damaged artery by placing stent grafts to prevent recurrence in segments with even minimal dilatation on initial evaluation.