The GenousTM stent coated with anti-CD34 antibodies has been designed to accelerate healing of the vessel by attracting

circulating endothelial progenitor cells. Rapid restoration of a functional endothelial layer with a full coverage of the stent

struts aims to minimise arterial injury after coronary stenting and to prevent thrombus formation and neointima proliferation.

We report a case of a 56 year-old man who developed a coronary artery aneurysm after the implantation of a GenousTM stent

due to an edge restenosis in sirolimus-eluting stent. We present diagnostics of our patient with the application of intravascular

ultrasound and coronary computed tomography angiography, discuss his management, and hypothesise about the pathomechanism

of aneurysm formation

Koziński, Marek

Kubica, Jacek

Radomski, Marek

Rychter, Marcin

Serafin, Zbigniew

Sukiennik, Adam

English

Repository of Nicolaus Copernicus University

www.kardiologiapolska.plKardiologia Polska 2012; 70, 6: 641–644 ISSN 0022–9032INVASIVE CARDIOLOGYCoronary artery aneurysm after implantation ofan endothelial progenitor cell capturing stentTętniak tętnicy wieńcowej po wszczepieniu stentuwiążącego komórki progenitorowe śródbłonkaMarcin Rychter1, Marek Radomski1, Adam Sukiennik1, Zbigniew Serafin2, Marek Koziński1, Jacek Kubica11Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland2Department of Radiology and Diagnostic Imaging, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, PolandA b s t r a c tThe GenousTM stent coated with anti-CD34 antibodies has been designed to accelerate healing of the vessel by attractingcirculating endothelial progenitor cells. Rapid restoration of a functional endothelial layer with a full coverage of the stentstruts aims to minimise arterial injury after coronary stenting and to prevent thrombus formation and neointima proliferation.We report a case of a 56 year-old man who developed a coronary artery aneurysm after the implantation of a GenousTM stentdue to an edge restenosis in sirolimus-eluting stent. We present diagnostics of our patient with the application of intravascularultrasound and coronary computed tomography angiography, discuss his management, and hypothesise about the patho-mechanism of aneurysm formation.Key words: endothelial progenitor cell capturing stent, aneurysm, IVUSKardiol Pol 2012; 70, 6: 641–644Address for correspondence:Marek Koziński, MD, PhD, Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University,ul. Curie-Skłodowskiej 9, 85–094 Bydgoszcz, Poland, tel: +48 52 585 40 23, e-mail: marekkozinski@wp.plCopyright © Polskie Towarzystwo KardiologiczneINTRODUCTIONCoronary artery aneurysm represents an uncommon findingafter coronary balloon angioplasty or stent implantation [1, 2].It is usually defined as a dilatation of the lumen of a coronaryartery exceeding the diameter of the normal vessel segmentsby at least 1.5 times [3]. The natural history and optimal the-rapy in patients with post intervention coronary artery aneu-rysm remain unclear.CASE REPORTWe report the case of a 56 year-old man with hyperlipida-emia, hypertension, and a history of non-ST-elevation my-ocardial infarction who was referred to our department dueto anterior ST-elevation acute myocardial infarction with on-going chest pain of three hours’ duration.The patient immediately underwent primary percuta-neous coronary intervention. The culprit lesion was loca-ted in the proximal segment of the left anterior descen-ding coronary artery (LAD) (Fig. 1). It was a restenotic le-sion at the proximal edge of a sirolimus-eluting stent (SES)implanted three years previously. Coronary angiographyalso demonstrated significant stenoses in the middle partof the LAD and in the right coronary artery (RCA). Afterintracoronary administration of abciximab and subsequ-ent aspiration thrombectomy, a GenousTM stent (OrbusNe-ich Medical Technologies, Fort Lauderdale, FL, USA) co-ated with anti-CD34 antibodies (3.5 ¥ 18 mm, 18 atm)was deployed in the culprit lesion overlapping by about 3 mmthe previously implanted SES. The procedure was unevent-ful and an excellent immediate angiographic result wasachieved (Fig. 1). Treatment of the other coronary lesionswas scheduled for a second session a few weeks later. Thepatient was discharged home in a good condition on theseventh postprocedural day.After three months, the patient was readmitted for elec-tive coronary angioplasties. An aneurysm in the proximalwww.kardiologiapolska.plMarcin Rychter et al.642LAD at the site of the previous GenousTM stent deploymentwas present in coronary angiography performed before theprocedure (Fig. 2). Intravascular ultrasound (IVUS) confir-med the presence of the aneurysm. Using special softwarededicated to colour imaging of blood flow (Volcano), weobserved blood flow from the lumen of the vessel towardsthe aneurysm (Fig. 3). However, there was a filling defectwith intense echogenicity within the aneurysm probablycaused by a residual thrombus. At the same session, theother coronary lesions were treated with stenting. Angio-plasty of the middle part of the LAD was completed withan optimal result, whereas stenting of the RCA was com-plicated by no-reflow phenomenon and periproceduralmyocardial infarction despite intracoronary abciximab ad-ministration with restoration of normal epicardial flow.The patient was discharged from the hospital and a coro-Figure 1. Critical edge restenosis in a sirolimus-eluting stent (on the left) and immediate effect after the GenousTM stent implanta-tion (on the right)Figure 2. A coronary artery aneurysm after the GenousTM stent placement in angiography in RAO and LAO viewwww.kardiologiapolska.plCoronary artery aneurysm after the GenousTM stent643nary computed tomography angiography (CTA) was sche-duled after eight weeks in order to monitor the coronaryaneurysm.CTA at eight weeks depicted no progression of the aneu-rysm and maintained optimal results within the first intraco-ronary stent (Fig. 4). Since the first admission to our depart-ment, the patient has been continuing dual antiplatelet the-rapy with aspirin and clopidogrel. During six months of fol-low-up, the patient remains asymptomatic.DISCUSSIONThe appearance of angiographic coronary artery aneurysmsafter coronary interventions is rare, with a reported incidencevarying between 0.3% and 6.0% [3]. Coronary artery aneury-sms have been detected from three days to up to four yearsafter drug-eluting stent (DES) implantation, and from six daysto up to six years after bare metal stent (BMS) placement [4].To the best of our knowledge, we report for the first timethe development of an aneurysm after the implantation ofFigure 3. A coronary artery aneurysm in intravascular ultrasound. Arrows on the left indicate stent struts. A filling defect withintense echogenicity linked with the stent struts on the right suggests a thrombusFigure 4. Computed tomography angiography five months after the GenousTM stent placement. The examination revealed a residu-al atheromatous plaque with calcification before the stent and no progression of coronary aneurysm (arrows); LAD — left anteriordescending coronary artery; Cx — circumflex coronary arterywww.kardiologiapolska.plMarcin Rychter et al.644a GenousTM stent coated with anti-CD34 antibodies. The Ge-nousTM endothelial progenitor cell (EPC) capturing stent is in-tended to accelerate healing of the vessel by attracting circu-lating EPCs which mature into endothelial cells and cover thestent struts to minimise vessel injury after coronary interven-tion and prevent both thrombosis and restenosis [5].There are about 30 case reports of aneurysms after DESin PubMed, mainly concerning sirolimus and paclitaxel [6,7], one case of an everolimus-eluting stent-related aneurysm[8], and one case of an aneurysm after a zotarolimus-elutingstent implantation [6]. The incidence of coronary aneurysmswas similar overall with DES compared to BMS (1.1% [18 of1,615] with DES and 0.8% [12 of 1,587] with BMS in thepivotal DES vs BMS randomised trials, in which a routine an-giographic follow-up was performed six to nine months afterthe initial procedure [4]. However, these studies applied a dif-ferent definition of coronary artery aneurysms as a vessel di-stension of 20% or more in diameter compared to the refe-rence vessel. Furthermore, in a real-world setting, most post-procedural coronary aneurysms are probably never diagno-sed due to asymptomatic course in the majority of cases.Residual dissection and deep arterial wall injury (rupture orresection of the vessel media) caused by oversized balloons orstents and high-pressure balloon inflations have all been associat-ed with coronary artery aneurysms after coronary intervention [3].A possible explanation for the aneurysm in our patient isthe creation of an ulcer and micro-haemorrhage at the site ofthe atheromatous plaque during the primary angioplasty. It islikely that a small dissection, which was not visible on conven-tional angiography, caused the formation of an ulcer and a mi-cro-aneurysm. In our case, another possible mechanism forthe aneurysm formation is stent malapposition that occurredlate after the procedure. This phenomenon is observed withIVUS in about 4% of cases after BMS implantation [9] and in12.1% of patients after DES stenting [10].DES delay the healing process secondary to the antipro-liferative action of the eluting drug, cell necrosis and/or apop-tosis resulting from the antimetabolite effect of the drug, andhypersensitivity reactions to the drug/polymer mixture on theDES [11]. Other reasons for stent malapposition are: regres-sion of the atheromatous plaque, the incidence of late positi-ve remodelling (vessel dilatation) at the site of the implantedstent, allergic reaction to stent components (more commonwith DES), and late dissolution of thrombotic material trap-ped behind the stent struts in case of primary angioplasty [9].In our case, IVUS showed a filling defect in the aneurysm,possibly due to a partially dissolved thrombus (Fig. 3).New generation DES and EPC capturing stents have beendesigned to improve the safety profile including the problemof late acquired stent malapposition. However, in our patient,stent covered with anti-CD34 antibodies failed to acceleratethe healing process. A large mass of neointima in the criticallyrestenotic lesion and a high pressure inflation might compressvasa vasorum in the peristent region and cause local necrosisof the vessel wall.We decided to use CTA to follow our patient, mainly toavoid an invasive coronary artery catheterisation. In somepatients, particularly in asymptomatic ones and those withsmall coronary aneurysms, the application of coronary CTAshould be considered as a non-invasive alternative. The effi-cacy of CTA for identifying coronary artery ectasias and aneu-rysms has been already proven [12].The natural history of post-intervention coronary aneu-rysms appears to be benign in most cases [1, 2]. Aoki et al. [4]proposed an individualised approach to coronary aneurysmsusing a combination of aneurysm size assessed by IVUS,expansion history, pathophysiology (true or false aneurysm),and symptoms to decide when and if to apply therapy alter-natives. Large and symptomatic pseudoaneurysms, rapidlygrowing true aneurysms, and especially dangerous infectiousaneurysms should be treated interventionally or surgically toavoid potentially life-threatening complications regardless ofthe stent type implanted. On the other hand, in conservativemanagement, long-term dual antiplatelet therapy to preventstent thrombosis and distal embolism is recommended [4].AcknowledgementsThe authors are grateful to Tomasz Fabiszak for his outstan-ding English language assistance.Conflict of interest: none declaredReferences1. Alfonso F, Pérez-Vizcayno MJ, Ruiz M et al. Coronary aneu-rysms after drug-eluting stent implantation: clinical, angiogra-phic, and intravascular ultrasound findings. J Am Coll Cardiol,2009; 53: 2053–2060.2. Ahn CM, Hong BK, Kim JY et al. Incidence and natural historyof coronary artery aneurysm developing after drug-eluting stentimplantation. Am Heart J, 2010; 160: 987–994.3. Slota PA, Fischman DL, Savage M, Rake R, Goldberg S. Fre-quency and outcome of development of coronary artery aneu-rysm after intracoronary stent placement and angioplasty. AmJ Cardiol, 1997; 79: 1104–1106.4. Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneu-rysms after drug-eluting stent implantation. J Am Coll CardiolCardiovasc Interv, 2008; 1: 14–21.5. Aoki J, Serruys PW, van Beusekom H et al. Endothelial proge-nitor cell capture by stents coated by antibody against CD34: theHEALING-FIM Registry. J Am Coll Cardiol, 2005; 45: 1574–1579.6. Lee YS, Kim KS, Chang SG. Three aneurysms developed in threedifferent drug-eluting stents. Eur Heart J, 2009; 30: 1309.7. Koziński M, Jabłoński M, Sukiennik A, Białoszyński T, Surman D,Kubica J. Tętniak prawej tętnicy wieńcowej po implantacji stentupokrywanego paklitakselem. Folia Cardiol, 2005; 12: 873–878.8. Zbinden R, Eshtehardi P, Cook S. Coronary aneurysm formationin a patient early after everolimus-eluting stent implantation.J Invasive Cardiol, 2008; 20: E174–E175.9. Mintz GS, Shah VM, Weissman NJ. Regional remodelling as thecause of late malapposition. Circulation, 2003; 107: 2660–2663.10. Hong M-K, Mintz GS, Lee CW et al. Late stent malapposition afterdrug-eluting stent implantation: an intravascular ultrasound ana-lysis with long-term follow-up. Circulation, 2006; 113: 414–419.11. Joner M, Finn AV, Farb A et al. Pathology of drug-eluting stentsin humans: delayed healing and late thrombotic risk. J Am CollCardiol, 2006; 48: 193–202.12. Leschka S, Stolzmann P, Scheffel H et al. Prevalence and mor-phology of coronary artery ectasia with dual-source CT coro-nary angiography. Eur Radiol, 2008; 18: 2776–2784.

Coronary artery aneurysm after implantation of an endothelial progenitor cell capturing stent

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Coronary artery aneurysm after implantation of an endothelial progenitor cell capturing stent

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