Cardiovascular Revascularization Medicine 12 (2011) 133.e7–133.e10

Case Report

Percutaneous treatment of an occlusive left main pseudoaneurysm: a rolefor multimodality imaging

Akshay Mishraa, Tilak Sirasenaa, Richard Slaughterb, Peter Pohlnerc, Darren L. Waltersa,⁎

aCardiology Program, The Prince Charles Hospital, Brisbane, Australia 4032bMedical Imaging, The Prince Charles Hospital, Brisbane, Australia 4032

cCardiac Surgery Program, The Prince Charles Hospital, Brisbane, Australia 4032

Received 12 November 2009; accepted 24 February 2010

Abstract A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia

⁎ Correspondingof Cardiology, The Pri4032, Australia. Tel.:

E-mail address: la

1553-8389/10/$ – seedoi:10.1016/j.carrev.2

was successfully treated with a covered stent. We report this rare complication of cardiac surgery forinfective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arisingfrom the body of the left main and causing compression of this vessel following his fourth redo aorticvalve replacement for staphylococcal endocarditis. The endocarditis had been successfully managedand ongoing infection was excluded. The patient was then treated percutaneously with a coveredstent that excluded the aneurysm and relieved the stenosis in the vessel.© 2011 Elsevier Inc. All rights reserved.

Keywords: Stents; Pseudoaneurysm; Endocarditis

1. Introduction

We report a rare complication of cardiac surgery forinfective endocarditis (IE) with a root abscess. The patientdeveloped a pseudoaneurysm arising from the body of theleft main coronary artery causing compression of this vesselfollowing his fourth redo aortic valve replacement (AVR) forstaphylococcal endocarditis. The origin of the aneurysm wastreated with a covered stent.

2. Case history

A 51-year-old indigenous male presented for follow-up ofhis fourth redo AVR. Other medical history included beinghepatitis C positive. He was a smoker and a reformedintravenous drug user. In September 1989, he initially hadstaphylococcal IE of the aortic valve thought to be secondary

author. Associate Professor Darren Walters, Directornce Charles Hospital, Rode Rd. Brisbane, Queensland+61 7 3139 4000; fax: +61 7 3139 4715.h10@optusnet.com.au (D.L. Walters).

front matter © 2011 Elsevier Inc. All rights reserved.010.02.003

to drug abuse with severe aortic regurgitation (AR) andunderwent AVR with a bioprosthetic valve.

In January 1998, he again developed Aortic Valveendocarditis and a brain abscess and left ventricular septalabscess with severe AR and underwent a redo AVR withaortic root replacement utilizing a homograft valve. InOctober 2004, he was unfortunate enough to redevelop anaortic root infection with severe AR and underwent aorticroot re-replacement, again with a homograft valve.

In February 2006, he contracted IE of the homograft witha large peri-aortic abscess and severe AR for which heunderwent aortic root re-replacement.

In January 2008, he presented with NYHA Class 3dyspnoea and lethargy. A transoesophageal echocardio-gram showed multiple abscesses around the aortic rootand severe AR, moderate mitral regurgitation and tricuspidregurgitation, and ejection fraction of 35–43%. He wasre-operated on with aortic root replacement, mitral, andtricuspid valve repair. The aortic root abscess passed overthe roof of the left atrium adjacent to the left main trunk,passing behind the main pulmonary artery to involve thebase of the left atrial appendage. The abscess was widely

Fig. 1. (A) Computed tomography image showing a large pseudoaneurysm arising from the mid shaft of the left main coronary trunk and compressing the lumenof the vessel. (B) Magnetic resonance image showing a large pseudoaneurysm arising from the mid shaft of the left main trunk.

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debrided and the aortic root replaced with a newhomograft. Significant bleeding at operation necessitateddivision of the main pulmonary artery in order to repair theroof of the left atrium and close the base of the left atrialappendage, re-anastomosing the main pulmonary arteryfollowing reasonable haemostasis. Post surgery, he was inintermittent third-degree heart block for 10 days butgradually regained sinus rhythm.

Follow-up echocardiogram performed 6 months postsurgery identified a pseudoaneurysm of the left maincoronary artery. The aneurysm was further delineated withmultimodality imaging including cardiac magnetic reso-nance imaging (MRI) and computed tomography coronaryangiography (CTCA). This demonstrated a large pseudoa-neurysm arising from the mid body of the left main coronaryartery, compressing the left main to a slit-like narrowing(Fig. 1A and B). His logistic EuroSCORE was 10.5%, buthe was at higher risk of further surgery in view of multipleprevious operations. He was referred for percutaneous

intervention, a surgery considered very high risk. Therewas no evidence of infection, with C-reactive protein levelwithin normal limits, negative blood cultures on multipleoccasions, and no clinical evidence of active infection.While being evaluated, the patient became symptomaticwith episodes of pulmonary oedema and chest pain asso-ciated with systolic left ventricular dysfunction presumedto be related to left main stem ischaemia. An angiogramshowed a large proximal left main coronary arterypseudoaneurysm (Fig. 2A and B). There was a mid-vessel70% stenosis of moderate length, related to the pseudoa-neurysm compressing the left main artery. It was decidedto treat the origin of the aneurysm with a covered stent.The procedure was done electively.

An intravascular ultrasound (IVUS) of the lesion wascarried out (Fig. 2C). The size of the distal left main was3.5 mm and proximally 4.0 mm. The origin of the pseu-doaneurysm opening in the left main was identified. Leftmain was compressed at the mid segment. This left main,

Fig. 2. (A and B) Coronary angiography image demonstrating the left mainpseudoaneurysm arising from the body of the left main and compressing thelumen of the artery. (C) Intravascular ultrasound image showing the originof the pseudoaneurysm opening in the left main, while the left main vesselwas compressed at the mid segment to a slit-like narrowing.

Fig. 3. A repeat angiogram a month post procedure demonstrating aresolution of the pseudoaneurysm.

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including the origin of the aneurysm, was stented witha 3.5×19-mm covered stent (Abbott Graftmaster, AbbottVascular, Santa Clara, CA, USA). The vessel was post-dilated. The stent was then post dilated with a 4.0×12-mmQuantum Maverick (Boston Scientific, Natick, MA, USA)noncompliant balloon at 20 atm. There was no residual ste-nosis postdilatation. Postprocedure angiogram showed a tri-vial leak. Postprocedure IVUS showed a well-expanded stent.

The patient was reviewed with a repeat angiogram in amonth's time (Fig. 3). There was no evidence of residualblood flow into the pseudoaneurysm. At 1-year clinicaland CTCA follow-up, the patients were well with no evi-dence of pseudoaneurysm.

3. Discussion

Pseudoaneurysms of the left main trunk are exceedinglyrare, and isolated reports have been described in inflamma-tory diseases such as Takayasu's or Behçet's disease, as adirect result of valvular endocarditis and due to infection ofa coronary stent [1,2]. In addition, mitral-aortic interval-vular fibrosa pseudoaneurysms are common in patients withAVR for IE and may compress the left main [3]. However,an iatrogenic pseudoaneurysm as we have described isunique. It is our hypothesis that the pseudoaneurysm was theresult of an unrecognised perforation or puncture of the leftmain during the debridement of the root abscess and valvereplacement. The possible complications from these arerupture, tamponade, arterial occlusion, and sudden death[4,5]. There may also be shifting of the thrombus and distalocclusion of the vessel.

CTCA and MRI are valuable tools for delineating theanatomy and relationship of the pseudoaneurysm to adjacent

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structures. The approach to treatment can be planned andresponse to intervention assessed at follow-up [6].

Covered stents can be used as an alternative to surgery inthe management of these aneurysms [7–9]. Autologousvenous covered stents and polytetrafluoroethylene (PTFE)covered stents have been used for coronary dissections andsaphenous venous graft disease. PTFE stents are balloonexpandable slotted tube coronary stents made of implantablehigh-grade steel and made by sandwiching a layer of PTFEbetween two stents [8].

Unprotected left main stenting is a high-risk interven-tion but should be used once the surgical option is no longerviable. Multimodality imaging tools that are currentlyavailable such as CTCA, cardiac MRI, transoesophagealand transthoracic echocardiography, and IVUS should beutilized to plan and execute the procedure for optimal result.

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