Images in Cardiovascular Medicine
Coronary Artery Aneurysm After Drug-Coated Balloon Angioplasty for Chronic Total Occlusion
2023 Volume 87 Issue 7 Pages 1035-
Details
2023 Volume 87 Issue 7 Pages 1035-
A 50-year-old man presented with worsening angina pectoris. Coronary angiography (CAG) revealed chronic total occlusion (CTO) of the proximal left anterior descending (LAD) artery. Percutaneous coronary intervention (PCI) was electively performed after confirming significant ischemia (Figure A). Intravascular ultrasound (IVUS) following smooth insertion of guidewire and 2.0-mm balloon angioplasty, revealed that the CTO lesion comprised a shrunken vessel with collateral arteries crossing into the media (Figure B). Subsequent 3.0-mm scoring balloon angioplasty resulted in sufficient luminal expansion, providing suitable angiographic findings for drug-coated balloon (DCB) angioplasty. Therefore, 3.0/30-mm and 2.5/30-mm SeQuent PleaseTM (B. Braun Melsungen AG, Germany) balloons were used with the expectation of late lumen enlargement of the proximal and mid-LAD, respectively (Figure C,D; Supplementary Movies 1,2). The clinical course was uneventful under 3-month dual-antiplatelet therapy and subsequent aspirin monotherapy; however, anterior ST-segment elevation myocardial infarction occurred 4 months post-PCI. CAG revealed diffuse luminal ectasia and acute occlusion of the proximal- and mid-LAD, respectively (Figure E). IVUS revealed coronary artery aneurysms (CAAs) with medial disruption in the proximal LAD and thrombotic occlusion in the mid-LAD (DCB angioplasty-related CAAs) (Figure F,G). A 2.5/20-mm covered stent was implanted over the mid-LAD CAA to treat residual thrombotic stenosis post-balloon angioplasty (second PCI; Figure H).
Coronary angiography: (A) initial (yellow arrows, collateral arteries) and (C) post-DCB angioplasty; (E) ST-segment elevation myocardial infarction (STEMI), (F) post-thromboaspiration, and (H) post-implantation of the covered stent. Intravascular ultrasound: (B) initial and (D) post-DCB angioplasty, and (G) post-thromboaspiration at STEMI. Medial disruption (white arrowheads and arrows) due to collateral arteries (*), and procedure-related dissection (yellow arrowheads). DCB, drug-coated balloon.
PCI-related major coronary artery dissection is reportedly associated with DCB angioplasty-related CAA due to delayed vascular healing by antiproliferative drugs,1 as was observed in the present case. Besides procedure-related dissections, pre-existent disrupted medial structures with/without intraluminal collateral arteries were potentially associated with the CAA in the proximal LAD CTO. Therefore, the applicability of DCB angioplasty for CTO should be carefully considered based on intravascular images despite optimal angiographic findings.
None.
Supplementary Movie 1. Coronary angiography.
Supplementary Movie 2. Intravascular ultrasound.
Please find supplementary file(s);
https://doi.org/10.1253/circj.CJ-23-0149
