Images and Case Reports in Interventional Cardiology Stent-Assisted Coil Embolization of a Large Fusiform Aneurysm of Proximal Anterior Descending Artery Novel Treatment for Coronary Aneurysms

A 37-year-old Asian American man presented with severe stable angina of recent onset over a period of 3 weeks. He was an active policeman, whose only significant past medical history was a prolonged febrile illness with a rash at age 5. Exercise myocardial perfusion stress test was strongly positive with ST depression in inferolateral leads and large reversible perfusion defects in the inferior, inferolateral, and lateral walls of the left ventricle. Cardiac catheterization revealed a large fusiform aneurysm of the proximal left anterior descending (LAD) artery, ectasia of the proximal circumflex artery with 95% narrowing, and an occluded right coronary artery with an occluded proximal aneurysm. (Figure 1). Coronary CT angiogram showed 3-dimensional extent of the aneurysms, stenoses, and, in particular, the LAD aneurysm’s relation to the main pulmonary artery. The LAD aneurysm measured 11.7 17.7 24.2 mm, with a 2.5-mm diagonal artery arising from the side wall. (Figure 2). Percutaneous intervention of the circumflex artery was performed with a 3.0 23-mm MultiLink Vision stent (Abbot Vascular), which was post-dilated progressively with noncompliant balloons. The patient was treated with aspirin and clopidogrel. Subsequently, stent-assisted coil embolization of the aneurysm was performed. Informed consent was obtained after careful discussion with the patient, regarding indications, potential benefits, and alternatives. Intravenous heparin was used to keep the activated clotting time 300 seconds during the entire procedure. Initially, the LAD was wired with a 0.014-inch Cougar wire (Medtronic). A Progreat microcatheter (Terumo Corp) was placed inside the aneurysm. A 3 33-mm Zeta Multilink (Abbot Vascular) was then placed in the LAD at low pressure, entrapping the microcatheter. An Azuro coil (Terumo Corp), measuring 2 50 cm was subsequently deployed, wrapping around the stent. (Figure 3) The microcatheter was then removed, and post-dilation of the stent, especially inside the mother vessel, both proximally and distally, were performed. Intraprocedural intravascular ultrasound and Chromaflow (Volcano Corp) was used to systematically evaluate the extent of the aneurysm, stent apposition, coil deployment, and blood flow dynamics inside the aneurysm, within and without the stent struts. An immediate post-coil embolization angiogram showed preservation of flow, not only in the LAD but also in the diagonal branch. Intravascular ultrasound and the Chromaflow imaging of the aneurysm showed reduced flow and Figure 1. Coronary angiogram showing a proximal aneurysm of the left anterior descending (LAD) artery and ecstatic circumflex artery with severe stenosis inside the ecstatic segment.