Challenging case presentation Alok Sharma University of Minnesota

Disclosures I have no disclosures pertinent to this talk.

HPI: 67 y/o male presented to the ER with left wrist pain. Diagnosed with septic arthritis after arthrocentesis. Complained of exertional chest pressure along with atypical sharp pain with lying down and deep inspiration. Past Medical History: History of solitary kidney, traumatically injured in 1995. Initiated on hemodialysis in 2004. Diseased donor kidney transplant in 2005 which failed in 2006. Initiated on peritoneal dialysis in 2006. Hypertension. Hyperlipidemia. Extensive h/o CAD

Coronary artery disease history 7/2006: NSTEMI with PCI of proximal LAD with Sirolimus (Cypher) 3 x 33 mm DES and PCI of proximal to mid RCA with 4 x 20 mm chromium cobalt BMS. 12/15/2011: NSTEMI with 95% ostial RCA and 70% in-stent restenosis mid RCA. 4.0x 12 mm Everolimus eluting stent (Promus Element) to proximal RCA 3.5 x 10 mm Everolimus eluting stent to mid RCA.

1/12/2012: NSTEMI secondary to thrombotic occlusion of prox RCA stent, possible clopidogrel noncompliance. Aspiration thrombectomy with restenting ostial-proximal RCA with overlapping 3.5 x 12 mm and 4 x 12 Everolimus DES (promus element). Switched to Prasugrel. Massive lower GI Bleed requiring 9 U of PRBCs, POD #2 Colonoscopy: 2 active AVMs, photocoagulated / clipped. Switched back to Clopidogrel

1/25/2012: NSTEMI with in-stent thrombosis proximal RCA Aspiration thrombectomy IVUS: ostial segment not stented, stent gap between proximal and mid segments. Placement of 4.0 x 20 mm Everolimus DES (Promus Element) from ostial to prior distal stent edge. IVUS: good stent expansion. Plavix non responder and switched to prasugrel

3/7/2012: Recurrent NSTEMI, acute thrombotic occlusion proximal RCA CT Surgery consulted but hemodynamic instability prompted repeat PCI Emergent thrombectomy and placement of 4.0 x 28 mm BMS (vision) stent. IVUS: small area of mal-apposition in the mid segment. Post dilated at high pressure with good result. Switched to prasugrel 10 mg BID.

7/9/2012: NSTEMI with significant in-stent restenosis of proximal RCA Placement of 3.5 x 26 mm Zotarolimus eluting stent (Resolute).

Now Back to current presentation……. Physical exam: BP: 110/60 HR: 80 in sinus rhythm. Mild distress. Normal JVP, no murmurs. Two component friction rub best over the right third intercostal space. Lungs clear. EKG showed no significant ST-T changes. Troponin I was 0.08 ng/ml. Worsening chest pain and extensive prior CAD history, urgent coronary angiography was performed.

Coronary Angiogram Right radial approach 5F. Stent fracture in the proximal RCA stent with clear separation of the proximal and distal portions of the stents. (Type IV stent fracture). At the site of stent fracture a large expanding pseudoaneurysm of the proximal RCA. Pseudoaneurysm measured 15 mm in maximum dimension. Right radial approach via 4 F JR4 and JL4. Angiogram showed small aorto-ostial dissection flap in the inferior border at the proximal edge of the ostial stent .

Stent Fracture

Cardiothoracic surgery was consulted emergently for coronary artery bypass and resection of pseudoaneurysm. Deemend high risk surgical candidate due to untreated wrist infection and being on prasugrel. Therefore, we decided to put a polytetrafluoroethylene-covered stent (JOSTENT®, Abbott Vascular; Redwood City, Calif ) to treat the pseudoaneurysm. Converted from right radial to 7 F right femoral access.

Successfully treated with 4 Successfully treated with 4.0 x 19 mm covered JoStent and post dilated with 4 X 8 mm non compliant balloon at 18 ATM. Perforation was well sealed. No edge dissection with TIMI 3 flow in distal RCA.

Clinical Course Echo showed no pericardial effusion. Ejection fraction was 45% with inferior wall hypokinesis which was old. Doing well with no clinical events 7 months post procedure.

Conclusions Coronary artery stent fracture occurs rarely (0.6-8%). Stent fracture results in complications that include instent restenosis, stent thrombosis, acute coronary syndromes, sudden cardiac death, coronary aneurysms. Common predisposing factors for stent fracture. - RCA location. - Overlapping stents. - Use of longer stents. - Increased vessel tortuosity. - Overexpansion and overstretching of stent. - Myocardial bridging - Higher incidence with use of drug eluting stents esp Cypher stent.

The reported treatments have been - Conservative (in small pseudoaneurysms) - Surgical - Percutaneous, including coil embolization and covered stent placement. Coronary stent fracture and coronary pseudoaneurysm can be successfully treated with covered stent placement especially when surgery cannot be performed.

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Acknowledgements Dr. Robert Wilson Dr. Alan Berger Dr. Ganesh Raveendran Dr. Demetris Yannopoulos Dr. Uma Valeti Dr. Mark Pritzker