Long coronary artery aneurysm treated by two graft stents on a single bare metal stent scaffold

Dear editor,

We have read the recent case report by Król et al. [1] with great interest. The authors reported a case with giant aneurysm in the left anterior descending artery which was treated with two stent grafts on a bare metal stent scaffold.

We have also reported a 61-year-old male who suffered from stable angina pectoris. He had no history of coronary artery disease but he was diabetic for 5 years, hyper­tensive for 15 years and on statin treatment for hypercholesterolemia and he had never smoked. He had no family history for coronary artery disease. Coronary angiography revealed a giant aneurysm on the mid portion and a significant stenosis on the distal portion of the circumflex artery (Cx) (Figure 1). The right coronary artery was non-dominant and had a 50% stenosis on the mid portion. The first diagonal branch of the left anterior descending artery was diffusely atherosclerotic and the first obtuse marginal branch of the circumflex artery was occluded but both vessels were diminutive in diameter. Angioplasty was planned for stenosis and aneurysm on the Cx. But the aneurysmatic segment was unreachable for the single graft stent placement because of the angled nature of the Cx and the limited flexibility of graft stents associated with their double-layered strut profile. The strategy was planned as deployment of two graft stents over a single longer bare metal stent (BMS) as a scaffold. A 2.75 mm × 9 mm BMS (Ephesos II stent system, Alvimedica, Turkey) was deployed at 8 atm to the distal Cx lesion, successfully. Then a 3.0 mm × 25 mm BMS (Ephesos II stent system, Alvimedica, Turkey) was deployed onto the aneurysm at 12 atm by covering the proximal and distal healthy segments. Subsequently a 3.0 mm × 16 mm graft stent (Jostent Graftmaster, Abbot vascular, US) was deployed at 15 atm onto the proximal part of the BMS and then a 3.0 mm × 12 mm graft stent (Jostent Graftmaster, Abbot vascular, US) was deployed at 15 atm onto the distal part of the BMS, and the overlap segment of the stents was post-dilated by a 3.0 mm × 12 mm non-compliant balloon (Quantum Maverick Balloon, Boston Scientific, US) at 20 atm. Angiography revealed complete covering of the aneurysmatic segment without loss of main side branches (Figure 2). The patient was discharged the next day with optimized medical treatment. At 1st month, 6th month,

1st year and 2nd year follow-ups the patient was on medication and asymptomatic.

Both reports emphasized the innovative treatment of long coronary aneurysms by multiple graft stents on a bare metal stent scaffold. This technique might be useful in coronary aneurysms longer than commercially available graft stent sizes and in aneurysms which are unreachable due to the inflexibility of the graft stent and angled nature of the coronary artery.

Acknowledgments

The authors have no conflict of interest or financial support for this work.

References

1. Król M, Skwarna B, Gałuszka G, et al. Giant aneurysm in medial anterior descending artery: treatment with two endovascular stent grafts on bare metal stent scaffold. Postep Kardiol Inter 2011; 7:

173-177.