Circulation. 2007;116:e364-e365
doi: 10.1161/CIRCULATIONAHA.107.716076
(Circulation. 2007;116:e364-e365.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Pseudoaneurysm and Intracardiac Fistula Caused by an Infected Paclitaxel-Eluting Coronary Stent
James J. Jang, MD;
Ashok Krishnaswami, MD;
Junming Fang, MD, PhD;
Mateo Go, MD;
Valerie C. Kwai Ben, MD
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.
Correspondence 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 james.j.jang{at}kp.org
A 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).
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Figure 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.
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Figure 2. Volume-rendered image from a 64-multislice computed tomographic scan of a pseudoaneurysm (arrowhead) and fistula (arrow) from an occluded RCA stent.
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Figure 3. Axial computed tomographic image of a pseudoaneurysm (arrowhead) and fistula (arrow) that extends from an occluded RCA stent into the RA.
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Figure 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.
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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.
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Figure 5. Histopathology from the RA wall reveals tissue necrosis with a predominance of neutrophils consistent with an abscess. Hematoxylin and eosin staining. Magnification, x100.
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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.
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Disclosures
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None.
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Footnotes
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The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/116/14/e364/DC1.
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References
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- 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.[CrossRef][Medline]
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- Marcu CB, Balf DV, Donohue TJ. Post-infectious pseudoaneurysm after coronary angioplasty using drug-eluting stents. Heart Lung Circ. 2005; 14: 85–86.[CrossRef][Medline]
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- Alfonso F, Moreno R, Vergas J. Fatal infection after rapamycin eluting coronary stent implantation. Heart. 2005; 91: e51.[Abstract/Free Full Text]
- 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.[CrossRef][Medline]
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- Ramsdale DR, Aziz S, Newall N, Palmer N, Jackson M. Bacteremia following complex percutaneous coronary intervention. J Invasive Cardiol. 2004; 16: 632–634.[Medline]
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Disclosures
References