Author + information
- Received November 20, 2009
- Revision received December 17, 2009
- Accepted December 24, 2009
- Published online June 1, 2010.
- Richard Pearl, MD,
- Mustafa Hassan, MD and
- R. David Anderson, MD, MS⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. R. David Anderson, University of Florida Health Science Center, 1600 SW Archer Road, PO Box 100277, Gainesville, Florida 32610-0277
A 75-year-old man with a history of coronary artery bypass grafting and recent pacemaker site infection was transferred to our institution for treatment of a descending aortic pseudoaneurysm. A computed tomography scan performed upon arrival also revealed a suspected mycotic aneurysm of the saphenous vein bypass graft to the circumflex coronary artery. Following infectious disease consultation, the descending aortic pseudoaneurysm was treated with an endograft, and the patient underwent cardiac catheterization. This revealed not only the pseudoaneurysm of the saphenous vein bypass graft to the circumflex (Fig. 1), but associated compression of the left internal mammary artery graft to the left anterior descending coronary artery (Fig. 2). Additionally, the patient was found to have an ischemic cardiomyopathy with an ejection fraction of 30% and anteroapical hypokinesis. Ventricular function had been normal just a few months before. The patient was deemed not to be a surgical candidate. Following a complete course of antibiotic therapy for methicillin-susceptible Staphylococcus aureus, repeat discussion with infectious disease specialists, and institutional review board approval for their off-label use, 2 Jostent Graftmaster (Abbott Vascular, Abbott Park, Illinois) prostheses were deployed in the saphenous vein graft to the native circumflex coronary artery (Fig. 3). This excluded the pseudoaneurysm, restored normal flow to the distal native circumflex (Fig. 4), and within 1 week resulted in decompression of the left internal mammary artery to the left anterior descending artery (Fig. 5). The patient was discharged home on long-term dual antiplatelet and suppressive antibiotic therapy. Follow-up echocardiography revealed normal left ventricular function.
Mycotic aneurysms remain an uncommon clinical occurrence, usually in the setting of infective endocarditis or endovascular infections. There are only a few case reports of mycotic aneurysms of the native coronary arteries and fewer in bypass grafts (1–4). Surgical treatment has been the mainstay of therapy but carries a high risk for those patients with multiple comorbidities. The percutaneous approach used in this patient offers a suitable alternative to surgery, but the long-term risk of recurrent infection is unknown.
- Received November 20, 2009.
- Revision received December 17, 2009.
- Accepted December 24, 2009.
- American College of Cardiology Foundation