Yonsei Med J.  2019 Sep;60(9):824-831. 10.3349/ymj.2019.60.9.824.

Coronary Artery Aneurysm after Second-Generation Drug-Eluting Stent Implantation

• Hong SJ
• Kim H
• Ahn CM
• Kim JS
• Kim BK
• Ko YG
• Hong BK
• Choi D
• Jang Y
• Hong MK

• KMID: 2457478
• DOI: http://doi.org/10.3349/ymj.2019.60.9.824

Abstract

PURPOSE
We evaluated the incidence, predictors, and prognosis of coronary artery aneurysm (CAA) after second-generation drug-eluting stent (DES) implantation.
MATERIALS AND METHODS
A total of 976 consecutive patients (1245 lesions) who underwent follow-up angiography after second-generation DES implantation were analyzed. Incidence and predictors of CAA were assessed, and clinical prognosis was compared with 34 cases of CAA after first-generation DES implantation using previous CAA registry data.
RESULTS
All 10 cases of CAA (0.80% per lesion) in 10 patients (1.02% per patient) were detected at follow up. Compared to lesions without CAA, those with CAA had greater involvement of the proximal segment (90% vs. 51%, p=0.014), a higher proportion of pre-intervention, a Thrombolysis in Myocardial Infarction score of 0 or 1 flow (80% vs. 16%, p<0.001), more chronic total occlusions (40% vs. 10%, p<0.001), and longer implanted stents (41.9±23.2 mm vs. 28.8±14.8 mm, p=0.006). As for CAA morphology, instances of CAA after second-generation DES were predominantly the single fusiform type (90%), whereas instances of CAA after first-generation DES were multiple saccular (47%) and single saccular (35%) types (p<0.001). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA after first-generation DES (15%), and no adverse events were observed in patients with CAA after second-generation DES over a median follow-up duration of 4.3 years (p=0.047, log-rank).
CONCLUSION
Although CAAs after second-generation DES implantation were detected at a similar incidence to that for CAAs after first-generation DES implantation, second-generation DES-related CAAs had different morphologies and more benign clinical outcomes versus first-generation DES-related CAAs.

Keyword

Coronary artery disease; drug-eluting stent; percutaneous coronary intervention

MeSH Terms

Aneurysm*
Angiography
Coronary Artery Disease
Coronary Vessels*
Drug-Eluting Stents*
Follow-Up Studies
Humans
Incidence
Myocardial Infarction
Percutaneous Coronary Intervention
Prognosis
Stents
Thrombosis

Figure

• 

  Fig. 1 Study population. *Angiographic data and clinical outcomes of 34 coronary artery aneurysms (CAAs) after first-generation drug-eluting stent (DES) were obtained from our CAA registry data. Aug, August.

• 

  Fig. 2 (A–J) Individual morphologies of 10 coronary artery aneurysms (CAAs) (Case 1 through Case 10) after second-generation drug-eluting stent (DES) implantation. White arrowheads indicate the development of CAAs. Detailed individual data are also presented in Table 1.

• 

  Fig. 3 (A) Morphologic classification of coronary artery aneurysms (CAAs) according to drug-eluting stent (DES) generation. (B) Clinical outcomes of CAAs according to DES generation. Major adverse cardiac event (MACE) included the composite of cardiac death, myocardial infarction, and stent thrombosis. PCI, percutaneous coronary intervention.

Reference

1. Alfonso F, Pérez-Vizcayno MJ, Ruiz M, Suárez A, Cazares M, Hernández R, et al. Coronary aneurysms after drug-eluting stent implantation: clinical, angiographic, and intravascular ultrasound findings. J Am Coll Cardiol. 2009; 53:2053–2060. PMID: 19477355.

2. Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneurysms after drug-eluting stent implantation. JACC Cardiovasc Interv. 2008; 1:14–21. PMID: 19393139.

3. Joo HJ, Yu CW, Choi R, Park J, Lee HJ, Kim JS, et al. Clinical outcomes of patients with coronary artery aneurysm after the first generation drug-eluting stent implantation. Catheter Cardiovasc Interv. 2018; 92:E235–E245. PMID: 29164770.

4. Ahn CM, Hong BK, Kim JY, Min PK, Yoon YW, Lee BK, et al. Incidence and natural history of coronary artery aneurysm developing after drug-eluting stent implantation. Am Heart J. 2010; 160:987–994. PMID: 21095290.

5. Zbinden R, Eshtehardi P, Cook S. Coronary aneurysm formation in a patient early after everolimus-eluting stent implantation. J Invasive Cardiol. 2008; 20:E174–E175. PMID: 18460723.

6. Kadakia MB, Epps KC, Julien ME, Ogbara J, Giri J, Kolansky DM, et al. Early aneurysm formation after everolimus-eluting stent implantation. Circ Cardiovasc Interv. 2014; 7:266–267. PMID: 24737336.

7. Goldberg A, Zdorovyak A, Rosenfeld I, Nordkin I. Early development of coronary artery aneurysms after implantation of biolimus-eluting stent with biodegradable polymer. Int J Cardiol. 2015; 184:487–488. PMID: 25756573.

8. Cutlip DE, Windecker S, Mehran R, Boam A, Cohen DJ, van Es GA, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007; 115:2344–2351. PMID: 17470709.

9. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018; 72:2231–2264. PMID: 30153967.

10. Slota PA, Fischman DL, Savage MP, Rake R, Goldberg S. Frequency and outcome of development of coronary artery aneurysm after intracoronary stent placement and angioplasty. Am J Cardiol. 1997; 79:1104–1106. PMID: 9114773.

11. Bell MR, Garratt KN, Bresnahan JF, Edwards WD, Holmes DR Jr. Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy. J Am Coll Cardiol. 1992; 20:1474–1481. PMID: 1452919.

12. Rab ST, King SB 3rd, Roubin GS, Carlin S, Hearn JA, Douglas JS Jr. Coronary aneurysms after stent placement: a suggestion of altered vessel wall healing in the presence of anti-inflammatory agents. J Am Coll Cardiol. 1991; 18:1524–1528. PMID: 1939956.

13. Finn AV, Nakazawa G, Joner M, Kolodgie FD, Mont EK, Gold HK, et al. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol. 2007; 27:1500–1510. PMID: 17510464.

14. Stähli BE, Camici GG, Steffel J, Akhmedov A, Shojaati K, Graber M, et al. Paclitaxel enhances thrombin-induced endothelial tissue factor expression via c-Jun terminal NH2 kinase activation. Circ Res. 2006; 99:149–155. PMID: 16794185.

15. Hofma SH, van der, van Dalen BM, Lemos PA, Mc-Fadden EP, Sianos G, et al. Indication of long-term endothelial dysfunction after sirolimus-eluting stent implantation. Eur Heart J. 2006; 27:166–170. PMID: 16249221.