|Year : 2022 | Volume
| Issue : 2 | Page : 105-108
Mycotic coronary aneurysm: A rare complication of percutaneous coronary intervention
Susheel K Malani, Pratik Satyajit Wadhokar, Rajendra V Patil, Digvijay D Nalawade
Department of Cardiology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
|Date of Submission||11-Jul-2022|
|Date of Acceptance||15-Jul-2022|
|Date of Web Publication||19-Aug-2022|
Pratik Satyajit Wadhokar
D-28, Emirates Hills, Somatane Phata, Off Mumbai-Pune Highway, Tal-Maval, Pune - 410 506, Maharashtra
Source of Support: None, Conflict of Interest: None
Coronary artery aneurysms are extremely rare, major causative factors associated with this condition are atherosclerosis, trauma, connective tissue disorders, vasculitis, idiopathic, mycotic, and congenital. We present a case of a 49-year-old male who underwent primary angioplasty for acute ST-elevation myocardial infarction and presented with chest pain, fresh ST elevation, and fever after 10 days of the index procedure. The patient was suspected to have subacute stent thrombosis along with some infective pathology. However, work up did not reveal any systemic localization, and blood cultures were negative. Coronary angiogram showed aneurysm of the left anterior descending artery (LAD) with Grade 3 thrombus in the proximal part of stent with thrombolysis in myocardial infarction (TIMI) II antegrade flow. A two-dimensional echo revealed mild left ventricular dysfunction with moderate pericardial effusion. Cardiac positron emission tomography scan confirmed the suspicion of a stent-related mycotic aneurysm. Therefore, the patient was managed with intravenous antibiotics, antiplatelets, and low-molecular-weight heparin, followed by newer oral anticoagulants.
Keywords: Coronary artery disease, mycotic aneurysm, pericardial effusion, primary angioplasty
|How to cite this article:|
Malani SK, Wadhokar PS, Patil RV, Nalawade DD. Mycotic coronary aneurysm: A rare complication of percutaneous coronary intervention. J Pract Cardiovasc Sci 2022;8:105-8
|How to cite this URL:|
Malani SK, Wadhokar PS, Patil RV, Nalawade DD. Mycotic coronary aneurysm: A rare complication of percutaneous coronary intervention. J Pract Cardiovasc Sci [serial online] 2022 [cited 2022 Oct 3];8:105-8. Available from: https://www.j-pcs.org/text.asp?2022/8/2/105/354133
| Introduction|| |
Coronary artery aneurysm is rare, but in recent years, advancements in imaging have led to increase in its diagnosis rate. The variable incidence between 0.3% and 4.9% has been reported among all the patients undergoing coronary angiography, with a predominance in males. These are mostly infected with Staph aureus which causes microembolization to vasa vasorum or invasion of the vessel wall. These aneurysms may lead to thrombus formation or embolism or rupture. Early infections can be controlled with antibiotics and anticoagulants. However, in late stage, surgical interventions may be required. The intent of this report is to discuss clinical presentation, investigations, and management of the patient with coronary artery aneurysm.
| Case Report|| |
A 49-year-old male presented with anterior wall ST-elevation myocardial infarction with mild left ventricular (LV) dysfunction in June 2021. He underwent successful primary angioplasty in myocardial infarction with stenting to proximal left anterior descending (LAD) (3.5 mm × 28 mm everolimus drug-eluting stent) at a local hospital [Figure 1]a. He was discharged without any complications. After 10 days, he experienced typical retrosternal chest pain with sweating and highgrade fever with chills, for which he was admitted to our hospital. Clinically, he had fever with pulse of 116 bpm, blood pressure 110/70 mmHg, and SpO2 of 98% on room air. Systemic examination was unremarkable. Laboratory findings showed leukocytosis (white blood cells [WBC] – 25000/m3). The electrocardiogram (ECG) showed QS pattern with ST elevation of 2 mm in leads V1–V4. Two-dimensional ECG revealed mild LV dysfunction with hypokinesia in LAD territory with LV ejection fraction –50%. Moderate pericardial effusion was noted with maximum of 19 mm, more laterally and posteriorly, thereby making it difficult for diagnostic pericardiocentesis. There was no mitral regurgitation, LV clot, or pulmonary arterial hypertension [Figure 1]c. Cardiac troponin I and creatine kinase myocardial band were found to be elevated (Troponin-I: 404 ng/ml and CPK-MB: 48 IU). Chest X-ray showed mild cardiomegaly and no evidence of pulmonary infection. He was suspected to have subacute stent thrombosis along with some infective pathology. He was immediately started on intravenous (IV) ceftriaxone along with low-molecular-weight-heparin (LMWH). Coronary angiography was deferred in view of high fever, stable hemodynamics, and absence of ongoing angina. The blood culture was sterile and tests for malaria, dengue, and typhoid antigens came negative. However, serum procalcitonin levels were raised (0.36ug/L). Later, coronary angiogram revealed aneurysm of stented segment of LAD with Grade 3 thrombus in the proximal part of stent and thrombolysis in myocardial infarction II antegrade flow [Figure 1]b. Cardiac computed tomography (CT) angiogram showed aneurysmal dilation of LAD in the proximal segment along the stent with maximum dimension of 6.3 mm. Filling defect could also be seen in stent causing more than 50% narrowing in the proximal 6 mm segment and 30%–40% in the rest of the stent with moderate pericardial effusion (thickness – 22 mm) [Figure 2]a and [Figure 2]b.
|Figure 1: (a) Right anterior oblique caudal view after successful PAMI showing stenting done to proximal LAD (3.5 mm × 28 mm everolimus drug-eluting stent) with TIMI III flow. (b) Right anterior oblique caudal view of coronary angiography showing aneurysm of stented segment of LAD with Grade 3 thrombus in the proximal part of stent and TIMI II antegrade flow. (c) Modified apical four-chamber view and modified PLAX echocardiography view showing Moderate pericardial effusion (19 mm). PAMI: Primary angioplasty in myocardial infarction, LAD: Left anterior descending, TIMI: Thrombolysis in myocardial infarction, PLAX: Parasternal Long Axis.|
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|Figure 2: (a) Cardiac CT angiogram showed aneurysmal dilation of LAD in the proximal segment along the stent with maximum dimension of 6.3 mm and filling defect seen in stent causing more than 50% narrowing in proximal 6 mm segment. (b) HRCT of thorax axial and coronal view showing left lower lobe collapse consolidation with moderate synpneumonic effusion. CT: Computed tomography, LAD: Left anterior descending, HRCT: High-resolution computed tomography.|
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Positron emission tomography scan showed mild basal septum hypoperfusion with evidence of linear increased metabolic activity along with the mid segment of LAD stent suggestive of inflammation in this region compatible with mycotic aneurysm [Figure 3]a. During the hospital stay, the patient developed cough with left pleuritic chest pain, for which he was evaluated with high-resolution CT and found to have left lower lobe collapse consolidation with moderate synpneumonic effusion [Figure 3]b. Based on these findings, the patient was escalated to higher IV antibiotics (piperacillin-tazobactam plus linezolid).
|Figure 3: FDG-PET scan with axial and coronal images showing mild basal septum hypoperfusion with evidence of linear increased metabolic activity along the mid segment of LAD artery stent. LAD: Left anterior descending, FDG: Fluorodeoxyglucose, and PET: Positron emission tomography. Above two are (a) Axial Images; Below two are (b) Coronal Images.|
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The patient responded well and was afebrile with improvement in his appetite. There were no new ECG changes or elevations in serial cardiac enzymes. Serial ECG showed gradual reduction in Pericardial Effusion (PE). Therefore, the patient was managed conservatively with IV antibiotics, antiplatelets, and LMWH followed by novel oral anticoagulant (NOAC). The patient was discharged from the hospital in stable condition. On follow-up visits, he showed remarkable improvement, had no new complaints, and pericardial effusion was completely resolved.
| Discussion|| |
Coronary artery aneurysm is defined as dilation of coronary artery by 1.5 times the diameter of reference normal artery. The major cause of coronary artery aneurysm is atherosclerosis and other causes include Kawasaki disease, iatrogenic complications, vasculitis, syphilis, trauma, and other infectious diseases.
Between 1812 and 2017, only 97 cases of mycotic coronary aneurysm were reported, and out of these, 86 cases appeared after the introduction of percutaneous coronary intervention with stents in 1986. On the basis of published literature, Aoki et al. proposed the classification of coronary stent implantation-induced aneurysm into three types. Type I aneurysm demonstrates rapid early growth with pseudoaneurysm formation which is detected within 4 weeks of implantation. Its rapid formation may be attributed to arterial injury related to the procedure. Type II aneurysm can be subacute to chronic after 6 months of stent placement and is usually detected when the patient comes for follow-up or incidentally during angiography for recurrent symptoms. Type III aneurysm is mycotic or infectious and Staphylococcus aureus is the most common microorganism causing microembolization to vasa vasorum or invasion of vessel wall in this type. In our case, we used the criteria proposed by Dieter, according to which at least three of the criteria must be present for the diagnosis of mycotic aneurysm which includes: placement of a coronary stent within the previous 4 weeks, bacteremia, fever, or increase in WBC count with no other cause, multiple repeat procedures performed through the same arterial sheath, or positive cardiac imaging. Our patient was admitted after 10 days of drug-eluting stent (DES) placement, had fever along with chills, as well as his WBC count was also elevated.
Further, in our case, the patient developed moderate pericardial effusion and responded well to escalated IV antibiotics and antiplatelets and LMWH followed by NOAC. Very few cases of purulent pericardial effusion have also been reported after postcoronary intervention and such infection usually increases the chances of mortality and morbidity.,
The cases of development of mycotic aneurysm after stent placement are rare. In 2005, Singh et al. reported the development of mycotic aneurysm in a patient where DES was given in LAD and a non-DES in the right coronary artery. Out of these, only DES got infected and produced mycotic aneurysms. In our case, everolimus-eluting stent was placed in LAD, whereas in a report by Singh et al., sirolimus-eluting stent was used.
The appropriate treatment for coronary artery aneurysm is dependent on the individual situation. Aoki et al. proposed that its treatment may be individualized depending on the history of the patient, size of the aneurysm, and its pathophysiology. In our case, the patient developed moderate pericardial effusion and subacute stent thrombosis with no complications of pseudoaneurysm, stent abscess, or septic shock. Therefore, the patient was managed with conservative medical treatment using IV antibiotics, antiplatelets, and LMWH followed by NOAC only.
Other option which has recently been introduced to manage encompasses conventional stent implantation, coil embolization, autologous saphenous vein-covered stent grafting, and polytetrafluoroethylene-covered stent graft. In patients who are symptomatic and have obstructive coronary artery disease or evidence of embolization leading to myocardial ischemia, surgical excision or ligation of aneurysm combined with coronary artery bypass grafting is the preferred option.
| Conclusion|| |
Mycotic aneurysms of coronary arteries are rare but serious, life-threatening conditions. These must be suspected in patients who develop fever and chest pain after stent implantation. Multimodality imaging can help for diagnosing such rare entities. Early onset infections may be controlled with antibiotics and anticoagulants. However, each case has to be managed individually as there are no guidelines due to the paucity of cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Appropriate consent of patient was taken before making the case report. As this is a case report the university guidelines do not require an ethical committee and/or Institutional ethical committee clearance for its scientific publication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]