Coronary aneurysm formation after paclitaxel-coated balloon angioplasty for in-stent restenosis of first-generation sirolimus-eluting stent implanted 9 years ago

Excerpt

A 60-year-old man implanted with a 4 Cypher™ sirolimus-eluting stent in his right coronary artery (RCA) 9 years ago was admitted due to effort angina. Coronary angiography (CAG) revealed in-stent restenosis (ISR) of the proximal RCA (Fig. 1A). Intravascular ultrasound (IVUS) (OptiCross™, Boston Scientific, MA, USA) showed thick plaque with ultrasonic attenuation at the culprit lesion (Fig. 1b). Balloon angioplasty was performed followed by paclitaxel application by a coated balloon (Fig. 1B). The final angiogram (Fig. 1C) showed acceptable re-dilatation of that stenotic lesion, and IVUS depicted greatly diminished neointimal tissues with no major vessel wall injury (Fig. 1a’–c’). Minimum lumen diameter post procedure of 3.24 mm was achieved. The 8-month follow-up of CAG revealed coronary aneurysm formation at the site of previously re-dilated lesion (Fig. 1D). IVUS showed remarkable asymmetric vessel enlargement (minimum and maximum lumen diameters: 3.19 and 5.70 mm, respectively) with 180° of malapposed stent struts (Fig. 1b’’) and evaginations between the stent struts at the adjacent aneurysm site (Fig. 1a’’, arrowheads). This patient was managed conservatively with prolonged dual antiplatelet therapy (DAPT). No adverse cardiac event has occurred for the following 32 months.

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