Author + information
- Wei-Chun Huang1,
- Chin-Chang Cheng1,
- Cheng Chung Hung1,
- Cheng-Hung Chiang1,
- Guang-Yuan Mar1 and
- Chun-Peng Liu1
Patient initials or identifier number
Relevant clinical history and physical exam
A 54 years-old retired professional sport men has history of smoking, hypertension, end stage renal disease with regular hemodialysis, diabetes mellitus foot s/p below the knee amputation, previous episode of complete AV block. He had received PTCA+stent for 2 times due to CAD 5 Years ago.
Relevant test results prior to catheterization
He suffered from inferior STEMI 2 months ago. At that time, bare metal stent was implanted over middle segment of RCA after removal of thrombus. IABP and temporal pacemarker were implanted due to unstable condition. Fortunately, he was discharge later on.
Relevant catheterization findings
Unfortunately, he suffered from chest tightness again one month ago. Angiography showed massive thrombus within and after previous stent with a small aneurysm formation over middle segment of RCA. After thrombus removal, a drug-eluting balloon was used to treat the in-stent thrombus lesions.
However, he suffered from fever and chillness off and on for 1-2 month and visited our emergent department. Vital signs: BP: 112/50 mmHg, PR: 88/min, RR: 24/min, BT: 37.6°C. A Gr 2 systolic murmur over apex was found. Blood culture showed GPC in group. After antibiotics was prescribed, trans-esophageal echo showed fresh vegetation(with high embolic potential) attached at right atrium anterior wall endocardium (near right coronary artery middle stented segment) and right coronary artery middle stented segment is focally dilated with vascular wall thickening, the possibility of regional and segmental mycotic aneurysm. Three-dimension CT showed suspected myotic aneurysm over RCA. After 4 weeks antibiotic treatment, coronary angiography revealed instent restenosis with a huge aneurysm over middle part of RCA and poor distal run off. Operation arranged and huge pseudoaneurysm found over RCA. After open the aneurysm, a kinking and tortion of metallic stent was noted. Removal of pseudoaneurysm and by pass surgery were done. The patient received continuous antibiotics treatment.
Coronaryaneurysm or pseudoaneurysm may occur after PCI due to rupture, atherosclerosis, PCI, infection, autoimmune, congenital heart disease or trauma. Mycotic stent considered while recent PCI presenting with septicemia, which mostly caused by Staphylococcus aureus (76.6%.).