1. Coronary bifurcation wide-neck aneurysm successfully treated by provisional Y-stent-assisted coil embolization
Gregory A. Sgueglia, MD, PhD
Interventional Cardiology
Santa Maria Goretti Hospital
Latina, Italy

2. Disclosures I will present off-label use of interventional devices
I have no conflict of interest related to this presentation

3. Clinical Background Male, 80-years-old
Hypertension, hypercholesterolemia
Previous CABG (LIMA>LAD, SVG>OM, SVG>PDA) in 1994
Admitted because of prolonged chest pain at rest with ECG changes in inferior leads (NSTEMI)
HR 76 bpm, BP 140/90 mmHg, SaO2 98%
Blood tests: increased creatinine (1.8 mg/dL) and cTnI (11.3 ng/dL)

4. Coronary Angiography Three-vessel disease
Occlusion of the venous grafts to OM and PDA
Patency of LIMA>LAD
Coronary aneurysm (6 x 7 mm) involving the LAD/D1 bifurcation site (proximal to the bypassed stenosis)

5. Coronary Aneurysm

6. Program PCI on RCA because of ECG signs Imaging of the aneurysm
Scheduled aneurysm exclusion

7. Aneurysm imaging Wide-neck coronary aneurysm
D1 is 1 mm proximal to the aneurysm

8. Aneurysm Exclusion: Rational
CASS registry (~20,000 patients, )1
reduced five-year actuarial survival relative to patients with CAD alone (74% vs. 83%, p=0.004)
Emory University (~30,000 patients, )2
5-year rate of death: 29.1%
independent predictor of death (HR 1.56, , p=0.04)
1Swaye PS et al. Circulation 1983;67:134-8.
2Baman TS et al. Am J Cardiol 2004;93:

9. Treatment Objectives Related issues
Safe and effective exclusion of the aneurysm
Preservation of D1 patency
Related issues
Surgery
high risk, comparable to a redo CABG
Covered stent implantation
loss of D1 because of its close proximity to the aneurysm
Coil embolization
risk of coil herniation into the coronary artery owing to the wide-neck configuration of the aneurysm

10. Technical Solution
1 Bare metal stent (3 x 15 mm) implantation in LAD (jailed wire in D1) to assist coil embolization by supporting packing into the aneurysm and avoiding any herniation into the coronary artery

11. Technical Solution
2 Rewiring of D1 and advancement of a 1.9 French (0.63 mm) microcatheter over a coronary wire into the aneurysmatic sac

12. Technical Solution
Stent type was chosen according to the maximum inscribed circle and the corresponding diameter among different 3 mm stents
Mortier P. PhD Thesis.

13. Technical Solution
3 Nice packing of Guglielmi detachable coils into the aneurysm

14. Complication…
Chest pain and ECG changes: acute thrombotic occlusion of D1

15. Technical Solution
4 Because of acute thrombotic occlusion of D1 (pannel A) due to coil prolapse (pannel B), a second stent is implanted according to the TAP technique (pannel C) A B C

16. Final Result

17. Six Months Follow-Up

18. Clinical Implications
Complications of coronary aneurysms include distal embolization of thrombus formed due to the abnormal flow pattern in the aneurysmatic sac or rupture leading to cardiac tamponade3
The exact incidence of these complications is unknown and indication for treatment and its best modalities are still debated
Treatments with substantial risk of complications both at short-term (surgery) and long-term (covered stents) cannot be first line
3Cohen P et al. Cardiology in Review 2008;16:301-4

19. Clinical Implications
According to the experience from stent-assisted coiling of intracranial aneurysms, incomplete embolization or late expansion of the aneurysmatic sac is rare as well as thrombus propagation into the vessel lumen leading to late stent thrombosis4
Coronary aneurysms involving bifurcation sites offer however special challenges to interventional treatment
Provisional Y-stent-assisted coiling is an effective and modular approach allowing simple, safe and staged treatment of coronary aneurysms involving bifurcations
4Wakhloo AK et al. Stroke 2008;39:3288

20. Many thanks to... Edoardo Pucci Daniela Verde Adelchi Saltarelli
Interventional Cardiology
Santa Maria Goretti Hospital
Latina, Italy
Adelchi Saltarelli
Roberto Cianni
Interventional Radiology