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Percutaneous coil embolization of a post-traumatic left anterior descending coronary artery pseudoaneurysm: a case
Joaquin Espinoza1, Marina Byer2, Moises Vasquez1
1Division of Internal Medicine, University of Miami, Leonard M. Miller School of Medicine, 1400 NW 12th Ave, Miami, FL 33136, USA.
Insights
Coronary artery pseudoaneurysm (PSA) is a rare condition. Percutaneous coiling successfully treated a PSA in a patient with a pericardial hematoma, offering a viable management option.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Coronary artery pseudoaneurysm (PSA) is a rare complication of percutaneous coronary interventions (PCIs), infection, or trauma.
- Established management guidelines for PSA are lacking due to its low incidence.
- This case highlights a rare presentation of PSA in an elderly male with multiple comorbidities.
Observation:
- A 78-year-old male presented with chest pain post-fall, revealing an enlarging pericardial hematoma.
- Computed tomographic coronary angiography identified a ruptured pseudoaneurysm in the mid-left anterior descending artery.
- Left heart catheterization confirmed the PSA and its contrast inflow from the saphenous vein graft to the diagonal artery.
Findings:
- The patient underwent successful percutaneous pseudoaneurysm coiling, occluding inflow from the diagonal artery and distal LAD.
- The procedure ensured the integrity of vital LAD branches, preventing further complications.
- No subsequent electrocardiogram changes or troponin elevation were observed post-intervention.
Implications:
- Percutaneous coiling is an effective treatment for coronary PSA, particularly in high-risk patients.
- This case suggests blunt chest trauma as a potential cause of coronary PSA, even without prior hemopericardium.
- The successful management of this complex case provides valuable insights for treating rare coronary artery pathologies.
Background:
Coronary artery pseudoaneurysm (PSA) is a rare occurrence linked to percutaneous coronary interventions (PCIs), infection, or chest trauma, lacking established management guidelines due to its low incidence.
Case Summary:
A 78-year-old male with a medical history of triple vessel disease, post coronary artery bypass grafting, heart failure, and chronic obstructive pulmonary disease, presented with intractable left-sided chest pain following a mechanical fall. The initial workup was positive for mildly elevated high-sensitivity troponin and brain natriuretic peptide raising suspicion for a pulmonary embolism; but chest computed tomography angiography revealed an enlarging pericardial haematoma. Further computed tomographic coronary angiography exposed a mid-left anterior descending (LAD) interrupted segment concerning for a contained ruptured PSA. Left heart catheterization confirmed the suspicion, showing a collection of contrast at the haematoma site following injection of contrast into the saphenous vein graft to the diagonal artery. The patient underwent percutaneous PSA coiling, successfully occluding blood inflows from both the first diagonal and distal LAD. There were no subsequent electrocardiogram changes or further elevation in troponin levels ensuring the integrity of the LAD vital branches.
Discussion:
Coronary PSA results from the dissection of at least one layer of the vessel wall leading to blood extravasation. Although they are usually associated with PCI complications, the absence of haemopericardium in prior imaging makes the recent blunt chest trauma the most likely cause of this patient's presentation. Percutaneous coiling of inflow vessels to PSAs proved to be a suitable option in this case of a patient with a history of sternotomy and an expanding pericardial haematoma.
