Sharma Raghav, Ruia Aditya Vikram
Department of Cardiology, Meditrina Hospital, Ambala 133001, Haryana, India.
Eur Heart J Case Rep. 2022 Apr 21;6(5):ytac175. doi: 10.1093/ehjcr/ytac175. eCollection 2022 May.
Coronary artery pseudoaneurysms (PSAs) are uncommon and have poorly understood natural history. Unlike true aneurysms, PSAs do not have all the three layers of the vessel in the aneurysmal wall. The PSAs are most commonly seen after an overzealous percutaneous coronary intervention (PCI) which causes damage to the vessel wall. They usually develop slowly after PCI and PSAs within a month of a PCI are not so common. The PSA may be asymptomatic or present with recurrent angina.
Here, we report a case of symptomatic PSA to right coronary artery (RCA). The patient had a myocardial infarction for which a PCI was performed to deploy a drug-eluting stent (DES) in the RCA. The patient had in-stent restenosis (ISR) within a week of PCI for which plain old balloon angioplasty (POBA) was performed. The patient continued to have unstable angina and within a month of POBA was diagnosed as a case of PSA by intravascular ultrasound. A covered stent was deployed which effectively sealed off the PSA and resumed normal blood flow to distal vessel. Patient has been doing well on medication [aspirin 75 mg once daily, atorvastatin 80 mg once daily, and P2Y12 platelet inhibitor (Ticagrelor) 90 mg twice daily].
The PSAs usually take 6-9 months to develop. However, PSAs have been reported within 1-2 months of PCI. This case also shows that PSAs can occur within a month of PCI. It is possible that over-aggressive and/or high-pressure dilatation and/or deep engagement during POBA performed to open up the ISR could have damaged the struts of the DES and compressed it against the vascular wall. The resultant vascular wall injury could have been the cause of early PSA formation in this case. Hence, cardiologists should be vigilant enough to suspect PSA, especially in a patient presenting with angina. The case also shows that covered stents are a viable option to treat early presentations of PSA.
冠状动脉假性动脉瘤（PSA）并不常见，其自然病史也鲜为人知。与真性动脉瘤不同，PSA的瘤壁中并不具备血管的所有三层结构。PSA最常见于过度积极的经皮冠状动脉介入治疗（PCI）后，这种治疗会对血管壁造成损伤。它们通常在PCI后缓慢形成，PCI后一个月内出现的PSA并不常见。PSA可能无症状，也可能表现为复发性心绞痛。
在此，我们报告一例右冠状动脉（RCA）出现症状性PSA的病例。该患者发生心肌梗死，为此在RCA中进行了PCI以植入药物洗脱支架（DES）。患者在PCI后一周内发生支架内再狭窄（ISR），为此进行了普通球囊血管成形术（POBA）。患者持续出现不稳定型心绞痛，在POBA后一个月内通过血管内超声被诊断为PSA病例。植入了覆膜支架，该支架有效地封闭了PSA，并恢复了远端血管的正常血流。患者通过药物治疗情况良好[阿司匹林每日一次75毫克，阿托伐他汀每日一次80毫克，P2Y12血小板抑制剂（替格瑞洛）每日两次90毫克]。
PSA通常需要6 - 9个月形成。然而，也有在PCI后1 - 2个月内出现PSA的报道。该病例也表明PSA可在PCI后一个月内发生。有可能在为开通ISR而进行的POBA过程中，过度积极和/或高压扩张和/或深度介入操作损坏了DES的支柱并将其压向血管壁。由此导致的血管壁损伤可能是该病例中早期PSA形成的原因。因此，心脏病专家应足够警惕以怀疑PSA，尤其是对于出现心绞痛的患者。该病例还表明，覆膜支架是治疗早期PSA的可行选择。
