Pseudoaneurysm and Intracardiac Fistula Caused by an Infected Paclitaxel-Eluting Coronary Stent
2007; Lippincott Williams & Wilkins; Volume: 116; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.107.716076
ISSN1524-4539
AutoresJames J. Jang, Ashok Krishnaswami, Junming Fang, Mateo Go, Valerie C. Kwai Ben,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoHomeCirculationVol. 116, No. 14Pseudoaneurysm and Intracardiac Fistula Caused by an Infected Paclitaxel-Eluting Coronary Stent Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBPseudoaneurysm and Intracardiac Fistula Caused by an Infected Paclitaxel-Eluting Coronary Stent James J. Jang, Ashok Krishnaswami, Junming Fang, Mateo Go and Valerie C. Kwai Ben James J. JangJames J. Jang From the Division of Cardiology (J.J.J., A.K., M.G., V.C.K.), Santa Teresa Medical Center, Kaiser Permanente, San Jose, and the Pathology Department (J.F.), San Francisco Medical Center, Kaiser Permanente, San Francisco, Calif. , Ashok KrishnaswamiAshok Krishnaswami From the Division of Cardiology (J.J.J., A.K., M.G., V.C.K.), Santa Teresa Medical Center, Kaiser Permanente, San Jose, and the Pathology Department (J.F.), San Francisco Medical Center, Kaiser Permanente, San Francisco, Calif. , Junming FangJunming Fang From the Division of Cardiology (J.J.J., A.K., M.G., V.C.K.), Santa Teresa Medical Center, Kaiser Permanente, San Jose, and the Pathology Department (J.F.), San Francisco Medical Center, Kaiser Permanente, San Francisco, Calif. , Mateo GoMateo Go From the Division of Cardiology (J.J.J., A.K., M.G., V.C.K.), Santa Teresa Medical Center, Kaiser Permanente, San Jose, and the Pathology Department (J.F.), San Francisco Medical Center, Kaiser Permanente, San Francisco, Calif. and Valerie C. Kwai BenValerie C. Kwai Ben From the Division of Cardiology (J.J.J., A.K., M.G., V.C.K.), Santa Teresa Medical Center, Kaiser Permanente, San Jose, and the Pathology Department (J.F.), San Francisco Medical Center, Kaiser Permanente, San Francisco, Calif. Originally published2 Oct 2007https://doi.org/10.1161/CIRCULATIONAHA.107.716076Circulation. 2007;116:e364–e365A 54-year-old man with end-stage renal disease presented with chest pain. Five months before presentation the patient had a right-foot cellulitis that was treated with amoxicillin clavulanate. Two weeks later, the patient suffered an inferior wall ST-elevation myocardial infarction that required immediate percutaneous coronary intervention with paclitaxel-eluting stents (Taxus, Boston Scientific, Natick, Mass) in the proximal and mid-right coronary artery (RCA). Over the next 4 months, the patient had recurrent fevers and grew Staphylococcus aureus on repeat blood cultures. The source of infection was attributed to recurrent infected dialysis catheters. The patient had 3 catheter replacements and was treated with intravenous vancomycin and oral rifampin. On examination, the patient had a continuous murmur along the right sternal border and an elevated troponin I level of 2.45 ng/mL (normal range: 0.00 to 0.09 ng/mL).Coronary angiography revealed an occluded proximal RCA stent (asterisks in Figure 1, and Movie I, online-only Data Supplement), a large pseudoaneurysm off the stent (arrowhead in Figure 1), and a fistula into the right atrium (RA) (arrow in Figure 1). A 64-slice multidetector computed tomographic angiogram (GE Healthcare, Chalfont St. Giles, United Kingdom) confirmed both the pseudoaneurysm (arrowhead in Figures 2 and 3) and fistula into the RA (arrow in Figures 2 and 3). Transesophageal echocardiogram (Siemens, Malvern, Pa) identified serpiginous echodensities (arrowhead in Figure 4A, and Movie II, online-only Data Supplement) along the RA wall consistent with vegetation and a fistula inflow from the RCA (arrow in Figure 4B, and Movie III, online-only Data Supplement). Download figureDownload PowerPointFigure 1. Pseudoaneurysm (arrowhead) and fistula (arrow) that extends from an occluded RCA stent (asterisks) into RA as seen by coronary angiography. RA indicates right atrium.Download figureDownload PowerPointFigure 2. Volume-rendered image from a 64-multislice computed tomographic scan of a pseudoaneurysm (arrowhead) and fistula (arrow) from an occluded RCA stent.Download figureDownload PowerPointFigure 3. Axial computed tomographic image of a pseudoaneurysm (arrowhead) and fistula (arrow) that extends from an occluded RCA stent into the RA.Download figureDownload PowerPointFigure 4. A, Transesophageal echocardiography shows serpiginous echodensities (arrowhead) along the RA wall consistent with vegetation. B, Color Doppler image demonstrates RA inflow from a fistula (arrow) that originated from the RCA.The patient underwent a resection of the RCA stents and pseudoaneurysm, evacuation of the RA vegetation, and coronary bypass to the distal RCA with a saphenous vein graft. Microscopic specimen from the RA revealed tissue necrosis with a predominance of neutrophils consistent with an abscess (Figure 5). The patient received intravenous nafcillin and oral rifampin for an additional 6 weeks after surgery. The patient is doing well 6 months after the operation. Download figureDownload PowerPointFigure 5. Histopathology from the RA wall reveals tissue necrosis with a predominance of neutrophils consistent with an abscess. Hematoxylin and eosin staining. Magnification, ×100.To date, there have been only 4 other reported cases of drug-eluting coronary stent infections.1–4 In all cases S. aureus bacteremia was responsible for causing mycotic stent complications. Although mycotic aneurysms, pseudoaneurysms, and abscesses have been previously reported in both bare-metal and drug-eluting stent infections, this is the first reported case of an infected coronary stent that developed an intracardiac fistula. The mechanism of drug-eluting stent infection is not well understood. Potential causes for drug-eluting stent infections include impairment of local immunosuppression and endothelialization caused by the paclitaxel or sirolimus released from the stent and/or bacteremia at the time of catheterization.1–4 In fact, Ramsdale et al reported that up to 17.7% of patients who underwent complex percutaneous coronary interventions had detectable bacteremia.5 Further investigation is warranted to determine whether drug-eluting stents have a higher propensity for contamination versus bare-metal stents and whether prophylactic antibiotics should be administered for drug-eluting coronary stent implementation, particularly in complicated percutaneous coronary interventions.The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/116/14/e364/DC1.DisclosuresNone.FootnotesCorrespondence to Dr James J. Jang, Division of Cardiology, Santa Teresa Medical Center, Kaiser Permanente, 270 International Cir, 2-North, 2nd Floor, San Jose, CA 95119. E-mail [email protected]References1 Le MQ, Narins CR. Mycotic pseudoaneurysm of the left circumflex coronary artery: a fatal complication following drug-eluting stent implantation. Catheter Cardiovasc Interv. 2007; 69: 508–512.CrossrefMedlineGoogle Scholar2 Marcu CB, Balf DV, Donohue TJ. Post-infectious pseudoaneurysm after coronary angioplasty using drug-eluting stents. Heart Lung Circ. 2005; 14: 85–86.CrossrefMedlineGoogle Scholar3 Alfonso F, Moreno R, Vergas J. Fatal infection after rapamycin eluting coronary stent implantation. Heart. 2005; 91: e51.CrossrefMedlineGoogle Scholar4 Singh H, Singh C, 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: 282–285.CrossrefMedlineGoogle Scholar5 Ramsdale DR, Aziz S, Newall N, Palmer N, Jackson M. Bacteremia following complex percutaneous coronary intervention. J Invasive Cardiol. 2004; 16: 632–634.MedlineGoogle Scholar eLetters(0) eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate. Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page. Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Pisani A, Braham W and Borghese O (2021) Coronary stent infection: Are patients amenable to surgical treatment? A systematic review and narrative synthesis, International Journal of Cardiology, 10.1016/j.ijcard.2021.09.030, 344, (40-46), Online publication date: 1-Dec-2021. Golouh V, Kobilica N and Breznik S Superficial Femoral Artery Pseudoaneurysm and Arterial Wall Destruction After Drug-Coated Balloon Treatment, Cureus, 10.7759/cureus.10527 Davidson L and Ricciardi M (2018) Coronary Artery Perforation Complicated by Pericardial Abscess Formation, Circulation: Cardiovascular Interventions, 11:2, Online publication date: 1-Feb-2018. (2016) Bau- und raumhygienische Anforderungen Krankenhaus- und Praxishygiene, 10.1016/B978-3-437-22312-9.00009-3, (769-818), . Bosman W, Borger van der Burg B, Schuttevaer H, Thoma S and Hedeman Joosten P (2014) Infections of Intravascular Bare Metal Stents: A Case Report and Review of Literature, European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2013.10.006, 47:1, (87-99), Online publication date: 1-Jan-2014. Hakeem A, Karmali K, Larue S, Bhatti S, Chilakapati V, Samad Z, Roth Cline M, Cilingiroglu M and Leesar M (2011) Clinical presentation and outcomes of drug-eluting stent-associated coronary aneurysms, EuroIntervention, 10.4244/EIJV7I4A79, 7:4, (487-496), Online publication date: 1-Aug-2011. Alfonso F, Pérez-Vizcayno M, Ruiz M, Suárez A, Cazares M, Hernández R, Escaned J, Bañuelos C, Jiménez-Quevedo P and Macaya C (2009) Coronary Aneurysms After Drug-Eluting Stent Implantation, Journal of the American College of Cardiology, 10.1016/j.jacc.2009.01.069, 53:22, (2053-2060), Online publication date: 1-Jun-2009. Laissy J (2009) Diseases Developing Coronaro-Bronchial Anastomoses Integrated Cardiothoracic Imaging with MDCT, 10.1007/978-3-540-72387-5_29, (417-423), . October 2, 2007Vol 116, Issue 14 Advertisement Article Information Metrics https://doi.org/10.1161/CIRCULATIONAHA.107.716076PMID: 17909110 Originally publishedOctober 2, 2007 PDF download Advertisement Subjects Computerized Tomography (CT) Echocardiography Imaging Myocardial Infarction Stent
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