- Email: [email protected]
Coronary mycotic aneurysm post Everolimus eluting stent
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 2 6 0 e2 6 2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Coronary mycotic aneurysm post Everolimus eluting stent Shuvanan Ray a,*, Siddhartha Bandyopadhyay b, David Rozario b, Sanjeev Mukherjee b, Prithwiraj Bhattacharjee c, Sabyasachi Mitra d a
Chief of Cardiac Intervention, Fortis Interventional Cardiology, Kolkata, West Bengal, India Consultant, Fortis Interventional Cardiology, Kolkata, West Bengal, India c Clinical Associate, Fortis Interventional Cardiology, Kolkata, West Bengal, India d RMO, Fortis Interventional Cardiology, Kolkata, West Bengal, India b
article info
abstract
Article history:
Mycotic aneurysm of coronary artery is rare and life-threatening. We report a case of
Received 22 September 2014
coronary artery mycotic aneurysm at the site of Everolimus eluting stent in a patient of
Accepted 24 October 2014
acute coronary syndrome.
Available online 15 December 2014
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Keywords: Acute coronary syndrome Everolimus eluting stent Mycotic aneurysm
1.
Introduction
The use of PCI and stent in the management of acute coronary syndrome has increased several folds over the last few decades. Post PCI infective aneurysm of coronary artery is a rare and life-threatening complication. Isolated case reports have shown fatal outcomes.1 Most of the cases reported in literature are associated with BMS implantations.2 We report a case of coronary artery mycotic aneurysm at the site of Everolimus eluting stent.
2.
Case
A 65 years old gentleman, with a history of inferior wall MI and stenting (CYPHER) to RCA 11 years ago, suffered an acute inferior wall MI and underwent coronary angioplasty with two overlapping Everolimus eluting stents in proximal RCA. After 2 weeks of angioplasty he developed septic arthritis with blood and joint fluid culture growing MRSA (Methicillin Resistant Staphylococcus Aureus). He also developed breathlessness. Echocardiogram showed large pericardial effusion.
* Corresponding author. Tel.: þ91 9830024266. E-mail address: [email protected] (S. Ray). http://dx.doi.org/10.1016/j.jicc.2014.10.004 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 2 6 0 e2 6 2
261
Fig. 1 e A. Mycotic aneurysm compressing RVOT. B. Mycotic aneurysm compressing RVOT.
His cardiac MRI revealed a huge aneurysm of the right coronary artery compressing RVOT (Right Ventricular Outflow Tract) (Fig. 1A and B) and coronary angiogram confirmed (Fig. 2A and B) He was sent for emergency surgery with explantation of stent and bypass graft to RCA and was haemodynamically stable at discharge.
3.
Discussions
Mycotic aneurysms constitute 2.6% of all aneurysms.3 Arterial trauma, immuno-compromised states, endocarditis, embolic occlusion of vasa vasorum, sepsis, injury due to immune complexes and congenital cardiovascular defects can predispose to aneurysm formation4,5 Mycotic aneurysms of coronary artery usually present with chest pain or sudden cardiac death and treatment involves appropriate antibiotics and prompt surgical intervention. Several mechanisms may be implicated in the development of mycotic aneurysms. Mycotic aneurysm after PCI without any antecedent infective endocarditis is rare. In our case whether Everolimus contributed to local infection is a point of debate. We know that Sirolimus causes immuno-
suppression by binding to specific cytosolic protein immunophilin in target cells. This complex then binds to specific regulatory kinase called mammalian target of rapamycin (mTOR) and inhibits its activity. Inhibition of mTOR suppresses cytokine-stimulated T-cell proliferation, which forms the basis of immuno-suppressive activity of Sirolimus.6 Gregory et al7 have shown that Sirolimus significantly impairs the healing process after autoimmune and mechanical injury after balloon dilatation in an experimental model. Thus Everolimus by a similar mechanism would have impaired healing process after arterial injury due to angioplasty and staphylococcal infection. The reason for rare occurrence of these cases is the small dose of drug which is delivered around the stent. But if infection does occur locally in the periprocedural period, it is likely to be very fulminant as has been shown in this case. There are isolated case reports of aneurysm by Sirolimus eluting stents.8 This probably is the first case where Everolimus eluting stent was associated with mycotic aneurysm.
4.
Conclusion
In patients with haemodynamically significant large pericardial effusion new diagnostic techniques like Cardiac MRI and CT scan should be used in special cases where etiology is not very apparent and patient has undergone recent cardiac intervention. Post PCI coronary aneurysm leak or rupture as a cause of pericardial effusion is rare but should be considered as rapid intervention can save lives.
Conflicts of interest All authors have none to declare.
references Fig. 2 e A. Selective coronary angiogram. B. Selective coronary angiogram mycotic aneurysm of mycotic aneurysm.
1. Liu JC, Cziperl DJ, Kleinman B, Loeb H. Coronary abscess: a complication of stenting. Catheter Cardiovasc Interv. 2003;58:69e71.
262
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 2 6 0 e2 6 2
2. Kauffman BA, Kaiser C, Pfisterer ME, Bonetti PO. Coronary stent infection: a rare but severe complication of percutaneous coronary intervention. Swiss Med Wkly. 2005;135:483e487. 3. Jewkes AJ, Black J. Infection of an abdominal aortic aneurysm from an appendix abscess. J Cardiovasc Smg. 1989;30:870e872. 4. Doig JC, Hilton CJ, Reid DS. Salmonella; a rare cause of subacute effusive. Constrictive pericardiaties. Br Heart J. 1991;65:296e297. 5. Weinstein L, Schlesinger JJ. Pathoanatomy, pathophysiology and clinical correlation in endocarditis (second of two parts). N Engl J Med. 1974;291:1122e1125.
6. Akselbond Y, Harding MW, Nelson PA. Rapamycin inhibits spontaneous and fibroblast growth factor beta-stimulated proliferation of endothelial cells and fibroblasts. Transplant Proc. 1991;23:2833e2837. 7. Gregory CR, Huie P, Billingham ME, Morris RE. Rapamycininhibits arterial intimal thickening caused by both alloimmune and mechanical injury. Transplantation. 1993;55:1409e1413. 8. Singh Harminder, Singh Charanjit, Aggarwal N, Dugal JS, Kumar A, Luthra M. Mycotic aneurysm of left anterior descending artery after sirolimus eluting stent implantation: a case report. Catheter Cardiovasc Interv. 2005;65:282e285.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Coronary mycotic aneurysm post Everolimus eluting stent Shuvanan Ray a,*, Siddhartha Bandyopadhyay b, David Rozario b, Sanjeev Mukherjee b, Prithwiraj Bhattacharjee c, Sabyasachi Mitra d a
Chief of Cardiac Intervention, Fortis Interventional Cardiology, Kolkata, West Bengal, India Consultant, Fortis Interventional Cardiology, Kolkata, West Bengal, India c Clinical Associate, Fortis Interventional Cardiology, Kolkata, West Bengal, India d RMO, Fortis Interventional Cardiology, Kolkata, West Bengal, India b
article info
abstract
Article history:
Mycotic aneurysm of coronary artery is rare and life-threatening. We report a case of
Received 22 September 2014
coronary artery mycotic aneurysm at the site of Everolimus eluting stent in a patient of
Accepted 24 October 2014
acute coronary syndrome.
Available online 15 December 2014
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Keywords: Acute coronary syndrome Everolimus eluting stent Mycotic aneurysm
1.
Introduction
The use of PCI and stent in the management of acute coronary syndrome has increased several folds over the last few decades. Post PCI infective aneurysm of coronary artery is a rare and life-threatening complication. Isolated case reports have shown fatal outcomes.1 Most of the cases reported in literature are associated with BMS implantations.2 We report a case of coronary artery mycotic aneurysm at the site of Everolimus eluting stent.
2.
Case
A 65 years old gentleman, with a history of inferior wall MI and stenting (CYPHER) to RCA 11 years ago, suffered an acute inferior wall MI and underwent coronary angioplasty with two overlapping Everolimus eluting stents in proximal RCA. After 2 weeks of angioplasty he developed septic arthritis with blood and joint fluid culture growing MRSA (Methicillin Resistant Staphylococcus Aureus). He also developed breathlessness. Echocardiogram showed large pericardial effusion.
* Corresponding author. Tel.: þ91 9830024266. E-mail address: [email protected] (S. Ray). http://dx.doi.org/10.1016/j.jicc.2014.10.004 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 2 6 0 e2 6 2
261
Fig. 1 e A. Mycotic aneurysm compressing RVOT. B. Mycotic aneurysm compressing RVOT.
His cardiac MRI revealed a huge aneurysm of the right coronary artery compressing RVOT (Right Ventricular Outflow Tract) (Fig. 1A and B) and coronary angiogram confirmed (Fig. 2A and B) He was sent for emergency surgery with explantation of stent and bypass graft to RCA and was haemodynamically stable at discharge.
3.
Discussions
Mycotic aneurysms constitute 2.6% of all aneurysms.3 Arterial trauma, immuno-compromised states, endocarditis, embolic occlusion of vasa vasorum, sepsis, injury due to immune complexes and congenital cardiovascular defects can predispose to aneurysm formation4,5 Mycotic aneurysms of coronary artery usually present with chest pain or sudden cardiac death and treatment involves appropriate antibiotics and prompt surgical intervention. Several mechanisms may be implicated in the development of mycotic aneurysms. Mycotic aneurysm after PCI without any antecedent infective endocarditis is rare. In our case whether Everolimus contributed to local infection is a point of debate. We know that Sirolimus causes immuno-
suppression by binding to specific cytosolic protein immunophilin in target cells. This complex then binds to specific regulatory kinase called mammalian target of rapamycin (mTOR) and inhibits its activity. Inhibition of mTOR suppresses cytokine-stimulated T-cell proliferation, which forms the basis of immuno-suppressive activity of Sirolimus.6 Gregory et al7 have shown that Sirolimus significantly impairs the healing process after autoimmune and mechanical injury after balloon dilatation in an experimental model. Thus Everolimus by a similar mechanism would have impaired healing process after arterial injury due to angioplasty and staphylococcal infection. The reason for rare occurrence of these cases is the small dose of drug which is delivered around the stent. But if infection does occur locally in the periprocedural period, it is likely to be very fulminant as has been shown in this case. There are isolated case reports of aneurysm by Sirolimus eluting stents.8 This probably is the first case where Everolimus eluting stent was associated with mycotic aneurysm.
4.
Conclusion
In patients with haemodynamically significant large pericardial effusion new diagnostic techniques like Cardiac MRI and CT scan should be used in special cases where etiology is not very apparent and patient has undergone recent cardiac intervention. Post PCI coronary aneurysm leak or rupture as a cause of pericardial effusion is rare but should be considered as rapid intervention can save lives.
Conflicts of interest All authors have none to declare.
references Fig. 2 e A. Selective coronary angiogram. B. Selective coronary angiogram mycotic aneurysm of mycotic aneurysm.
1. Liu JC, Cziperl DJ, Kleinman B, Loeb H. Coronary abscess: a complication of stenting. Catheter Cardiovasc Interv. 2003;58:69e71.
262
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 2 6 0 e2 6 2
2. Kauffman BA, Kaiser C, Pfisterer ME, Bonetti PO. Coronary stent infection: a rare but severe complication of percutaneous coronary intervention. Swiss Med Wkly. 2005;135:483e487. 3. Jewkes AJ, Black J. Infection of an abdominal aortic aneurysm from an appendix abscess. J Cardiovasc Smg. 1989;30:870e872. 4. Doig JC, Hilton CJ, Reid DS. Salmonella; a rare cause of subacute effusive. Constrictive pericardiaties. Br Heart J. 1991;65:296e297. 5. Weinstein L, Schlesinger JJ. Pathoanatomy, pathophysiology and clinical correlation in endocarditis (second of two parts). N Engl J Med. 1974;291:1122e1125.
6. Akselbond Y, Harding MW, Nelson PA. Rapamycin inhibits spontaneous and fibroblast growth factor beta-stimulated proliferation of endothelial cells and fibroblasts. Transplant Proc. 1991;23:2833e2837. 7. Gregory CR, Huie P, Billingham ME, Morris RE. Rapamycininhibits arterial intimal thickening caused by both alloimmune and mechanical injury. Transplantation. 1993;55:1409e1413. 8. Singh Harminder, Singh Charanjit, Aggarwal N, Dugal JS, Kumar A, Luthra M. Mycotic aneurysm of left anterior descending artery after sirolimus eluting stent implantation: a case report. Catheter Cardiovasc Interv. 2005;65:282e285.