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A NIGHTMARE FOR THE
INTERVENTIONAL
CARDIOLOGIST-DES STENT
ANEURYSM!
DR VARUN CHAWLA MD,DM
LIFECARE INSTITUTE OF MEDICAL
SCIENCES &
RESEARCH,AHMEDABAD,INDIA
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Disclosure Statement of
Financial Interest
• I, Dr Varun Chawla DO NOT have a
financial interest/arrangement or
affiliation with one or more
organizations that could be
perceived as a real or apparent
conflict of interest in the context of
the subject of this presentation.
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HISTORY
• 55 year old Male , no h/o HT, DM ,
non smoker
• H\o allergy to NSAIDs
• Past h\o Inferior Wall STEMI
presented with Unstable Angina
• CAG - TVD
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CORONARY ANGIOGRAM
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PCI
• PTCA with stenting of LAD and RCA
with DES
• 3.5 x 39mm Sirolimus eluting stent
implanted in LAD at 14 atm pressure
(postdilated at 18 atm)
• 3.0 x 39 mm SES implanted in the
RCA at 18 atm pressure .
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POST PCI RESULT
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• Procedure - uneventful
• Patient discharged in a stable
condition
• Readmitted after 20 days post PCI
with h/o fever , dyspnea and dry
cough for 5 days.
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PHYSICAL EXAMINATION
• Temp. -100 F
Pulse- 130/ minute irregularly irregular pulse
B P-120/80 mm Hg
Edema feet ; JVP-increased
CVS-Tachycardia, S1, S2- Normal, no additional Heart sounds or murmur.
RS-clear
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INVESTIGATIONS
Hb-12.1 gm%
WBC-15,450 (P-76%;L-24%)
Platelet-4.47x 105
/cu.mm
Blood Urea- 61 mg/dl
S. Creatinine-2 mg/dl
S. Na-127 meq/l ;S. K-4.7 meq/l.
Normal LFT,s
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• ECG-low voltage complexes and
Atrial Fibrillation with rapid
Ventricular Rate
• 2D Echo revealed Moderate
Pericardial effusion ,no e\o RA ,RV
collapse ,Normal LV and RV systolic
function, normal cardiac valves and
no PAH
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CORONARY ANGIOGRAM
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• Subsequently blood cultures grew Pseudomonas Aeruginosa
• Treated with antibiotics based on the Culture Sensitivity report-Piperacillin-Tazobactum,Amikacin
• 2 D Echo revealed a decrease in the size of pericardial effusion
• Fever subsided; patient afebrile after 7 days
• WBC counts and S. Creatinine returned to normal
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• Antibiotics continued
• Recurrence of fever after 7 days
• Broader spectrum coverage with
antibiotics given-Inj Meropenem
1gm iv 8 hrly ; Inj Vancomycin-1 gm
iv 12 hrly
• Fever subsided after 4 days
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• Antibiotics continued
• CAG - 2 weeks later
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REPEAT CAG
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DEFINITIVE TREATMENT
• Surgery
• Pericardial adhesions
• Sero-sanguinous pericardial fluid
• Large Aneurysms identified in
LAD;inflammed surrounding area
• LAD opened at the site of aneurysm;
Was thick and calcific
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• On opening aneurysm slough;putrefied,cheesy material
• Both Stents explanted
• Slough removed
• LAD ligated at this area
• LAD opened beyond the stent segment-clean lumen;no distal disease
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• SVG to LAD end to side anastomoses
done;Good distal flow achieved
• RCA-similar findings;Stent explanted
and vessel ligated at that level
• RCA opened distal to aneurysmal
segment –clean-no distal disease
• SVG to RCA anastomosis achieved
• SVG to Ramus anastomosis achieved
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POST OPERATIVE
• Stent and tissue sent for culture-
sterile
• Fever till 7 days post procedure;
none subsequently
• Antibiotics-4 weeks post CABG
• Stable-on discharge
• Uneventful clinical course since then
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TAKE HOME MESSAGE
• In a patient coming with unexplained
fever &/or pericardial effusion Post
PCI ,Stent Aneurysms should be
considered as a possibility
• Timely detection and appropriate
management crucial
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`
THANK YOU