Defusing a ticking time bomb: percutaneous intervention for a giant coronary pseudoaneurysm - a case report

Giant coronary pseudoaneurysms (PSAs) are extremely rare and typically managed surgically. Our case demonstrates an alternative approach with percutaneous intervention using covered stents. A 62-year-old male underwent percutaneous coronary intervention (PCI) to the left main (LM) and left anterior descending (LAD) arteries for non-ST elevation myocardial infarction (NSTEMI) complicated by cardiogenic shock in the setting of concurrent Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemia. During the planned staged PCI to the right coronary artery (RCA), a relook angiogram of the left coronary system revealed a giant LM-LAD PSA with evidence of coronary steal phenomenon. The staged procedure was aborted to allow for further evaluation and characterisation of the PSA. This was done through multi-modality cardiac imaging including transthoracic echocardiography (TTE) and computed tomography coronary angiography (CTCA). After a HEART team discussion, it was decided that the PSA would be treated percutaneously. This was done successfully with intravascular ultrasound (IVUS) guidance and deployment of covered stents from the LM-LAD. Repeat TTE images on day 1 post procedure showed thrombi formation within the PSA cavity and the interval TTE done 3 months post procedure showed complete resolution of the PSA. The patient remained symptom free and tolerating regular dialysis sessions. He unfortunately declined repeat CTCA imaging in the interim.

This showcases the importance of multi-modality imaging and a multidisciplinary approach in managing an unusual presentation of coronary PSA. The use of covered stents for treatment is feasible and allowed successful treatment of the giant PSA, avoiding potentially catastrophic complications.

Coronary PSAs are rare and associated with fatal complications. This case highlights the successful treatment of a giant coronary PSA percutaneously using covered stents.