Bypass graft stent fracture leading to saphenous vein graft pseudoaneurysm.

An 83-year-old man, with a history of coronary artery bypass graft surgery 19 years before presentation and subsequent percutaneous coronary intervention to saphenous vein graft with placement of a paclitaxel drug-eluting stent 16 years later, presented with a 2-week history of fevers, productive cough, and pleuritic chest pain. He was found to have leukocytosis and chest x-ray evidence of pneumonia with a widened mediastinum. He was admitted for treatment of protracted pneumonia. He had a borderline elevated troponin I, which, in the absence of anginal pain, was thought to be secondary to demand ischemia. A chest radiograph obtained at admission showed bilateral pleural effusions, a right lower lobe infiltrate, and a widened mediastinum (Figure 1A and 1B). An ECG was initially unremarkable (Figure 1C). Blood cultures were positive for methicillinsensitive Staphylococcus aureus, and despite antibiotic therapy, the patient became progressively hypotensive. A repeat ECG showed anterolateral T-wave inversions (Figure 1D). Chest computed tomography (CT) (Figure 2A and 2B) revealed a fractured stent and a giant aortocoronary saphenous vein graft pseudoaneurysm. Transthoracic echocardiography then revealed a mass that was compressing the right ventricular outflow tract, suggesting that the cause of the patient’s hypotension was low cardiac output due to right ventricular outflow tract obstruction (Figure 2C and Movies I and II in the online-only Data Supplement). The patient was believed to be too unstable for surgery, and therefore he was taken urgently to the cardiac catheterization laboratory for placement of a covered stent across the apparent graft perforation (Figure 2D), but the attempt was unsuccessful. The patient became progressively hypotensive and later expired in the coronary care unit. Although autopsy was declined by the family, the cause of death was thought to be heart failure due to a giant aortocoronary saphenous vein graft pseudoaneurysm caused by stent fracture. Stent fracture is a rare but increasingly recognized complication of percutaneous coronary intervention, usually occurring after placement of drug-eluting stents and stents placed in the right coronary artery.1 Little is known about the clinical presentation of stent fracture, but the most common presentation appears to be acute coronary syndrome, with unstable angina or non–ST-segment elevation myocardial infarction being reported the most frequently.2 In many cases, the long-term prognosis is benign.1 Sixty-four–slice CT coronary angiography has been shown to be more sensitive and specific for detection of stent fractures than conventional coronary cine angiography and coronary intravascular ultrasound.3 This case represents an unusual complication of stent fracture in which the diagnosis was apparent by CT imaging of the chest and was refined by echocardiography and coronary angiography.