case_images: PMC10762889_01
case_images: Initial presentation angiogram: A) left anterior oblique view of right coronary artery pre-drug-eluting stent implantation showing crescent-shape dye collection at site of near-total occlusion of the proximal right coronary artery; B) post-drug-eluting stent implantation shows disappearance of crescent-shaped dye collection. The white arrow shows the location of the previous drug-eluting stent implanted several years earlier. DES, drug-eluting stent; RCA, right coronary artery.
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case_images: Despite the patient's presentation being unusual for ST-elevation myocardial infarction (STEMI), he underwent emergent catheterization based on ECG, which showed 70% mid-left anterior descending and 80% distal circumflex stenoses with Thrombolysis in Myocardial Infarction (TIMI) 3 flow and 99% ostial RCA lesion with TIMI 3 flow with a very proximal crescent-shaped contrast collection with flow suggestive, but not definitive for, a communication with the extravascular space and possibly the aortic root (Figure 1A, see Supplementary material online, Video S1). Danvers, MA, USA). Drug-eluting stent (3 mm x 23 mm) was then implanted with disappearance of the crescent-shaped lesion (Figure 1B).
case_images: *(A) Transoesophageal echocardiogram on second presentation showing a large cystic structure (4.0 x 3.5 cm) on mid-oesophageal short-axis view at the aortic valve level, (B) computed tomography angiography showing right coronary artery pseudoaneurysm (between the arrows) abutting aortic root; the dense linear radio-opacity on the medial side of the pseudoaneurysm is a drug-eluting stent, (C) second presentation angiogram: left anterior oblique view of the right coronary artery showing the pseudoaneurysm labelled '*' and a temporary femoral dialysis catheter labelled '**', (D) percutaneous intervention of pseudoaneurysm: right coronary artery angiography after covered stent deployment in proximal right coronary artery. Note contrast flow distal to the covered stent into the pseudoaneurysm. DES, drug-eluting stent; RCA, right coronary artery.
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case_images: Transoesophageal echocardiogram showed a large cystic structure (4 cm x 3.5 cm) near the right aortic cusp extending into the atrioventricular groove suspicious for an RCA pseudoaneurysm (Figure 2A, see Supplementary material online, Video S2); there was no evidence of mitral valve vegetation and only mild to moderate mitral regurgitation. Electrocardiogram-gated computed tomography angiography demonstrated a large cystic structure (3.5 cm x 4 cm x 4.7 cm) abutting the proximal RCA posteriorly, suspicious for a pseudoaneurysm (Figure 2B). Angiography showed a giant RCA pseudoaneurysm (Figure 2C, see Supplementary material online, Video S3). Post-covered stent implantation angiography showed well-expanded stent with contrast free flowing into the pseudoaneurysm distal to the stent (Figure 2D, see Supplementary material online, Video S3B).
case_images: (A) Intraoperative view of the opened pseudoaneurysm showing covered stent and drug-eluting stent, (B) a schematic of the hypothesized position of the deployed covered stent and the coronary guidewire. The wire was hypothesized to pass through a stent strut preventing any catheters to traverse distally. Frequent passes of balloon catheters before and after covered stent placement caused right coronary artery transection at pseudoaneurysm site. (A) guide catheter, (B) aortic root, (C) covered stent, (D) coronary pseudoaneurysm, (E) coronary guidewire, (F) recently placed drug-eluting stent, (G) mid-right coronary artery, (H) old posterolateral branch drug-eluting stent. DES, drug-eluting stent; RCA, right coronary artery.
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case_images: Intraoperatively, the vessel segment between proximal and mid-RCA was found to be transected (Figure 3A).