Navigating triple therapy in a high-risk cardiac patient with a covered stent and embolic stroke: A case report

Abstract Introduction: Covered stents such as the newly emerging FDA approved papyrus stent plays a pertinent role in the management of coronary artery aneurysms. However, compared to conventional drug eluting stents, these are associated with significantly higher risk of stent thrombosis and target vessel revascularization, often requiring prolonged dual antiplatelet therapy. This case scenario highlights a rare and clinically challenging scenario: Triple therapy (DOAC plus DAPT) in a medically fragile patient with coronary artery aneurysm with covered stent placement and recent embolic stroke. In the treatment of coronary artery aneurysms, covered stents like the recently FDA-approved Papyrus stent are important. However, they have much greater risks of stent thrombosis and target vessel revascularisation than traditional drug-eluting stents, frequently requiring long-term dual antiplatelet therapy (DAPT). This case illustrates a unique and clinically difficult situation in which a medically fragile patient with a recent embolic stroke and a coronary artery aneurysm treated with a covered stent is treated with triple therapy (direct oral anticoagulant [DOAC] plus DAPT). Case Presentation A 77-year-old male with ischemic cardiomyopathy (LVEF 15-20%), chronic kidney disease, peripheral vascular disease, and prior abdominal aortic aneurysm repair presented with progressive chest tightness, dyspnea, and abdominal discomfort. ECG showed inferior ST elevations and lateral ST depressions. He was diagnosed with NSTEMI, and was initiated on aspirin, clopidogrel, enoxaparin, and nitroglycerin. Coronary angiography revealed severe (99%) mid-RCA stenosis adjacent to a 6-mm proximal aneurysm, mild ostial left main stenosis, and chronic total LAD occlusion. PCI with intravascular lithotripsy and drug-eluting stent placement in the mid-RCA was performed. Severe LV dysfunction and mitral regurgitation prompted IABP insertion. Following IABP removal, he decompensated with pulmonary edema and required emergent intubation. Persistent cardiogenic shock necessitated Impella CP support, vasopressors (epinephrine, norepinephrine), and inotropes (dobutamine). Repeat angiography confirmed stent patency but persistent proximal aneurysm dilation. Despite initial stabilization, he experienced ventricular fibrillation and recurrent pulmonary edema requiring. Surgery deemed him unsuitable for LVAD or surgical intervention due to comorbidities. Following readmission, neurological evaluation revealed small subacute infarcts, following which anticoagulation with enoxaparin (later apixaban) was initiated alongside DAPT (aspirin, clopidogrel). Due to persistent aneurysm risk, compassionate use PCI with a Papyrus-covered stent was successfully performed, with minor residual endoleak. Post-intervention, the patient stabilized clinically and was discharged on triple therapy, guideline-directed heart failure therapy, dual antiplatelets, and apixaban. Discussion: In this setting, triple therapy was necessary to reduce thrombotic risks associated with the covered stent, coronary artery aneurysm, and embolic stroke. However, this strategy significantly increases bleeding risk particularly given the patient's advanced age and renal dysfunction. There is currently little data supporting triple therapy in these challenging situations, highlighting the necessity of individualized risk-benefit analyses. Efforts need to be made to potentially reduce the duration of therapy by balancing thrombosis prevention with bleeding risk. Repeat coronary angiography plays a major role here, allowing physicians to assess stent integrity and to make informed decision about de-escalation or continuation of therapy. Unfortunately, there are no current guidelines specifically addressing management strategies for patients with coronary artery aneurysms and recent embolic stroke, underscoring an urgent need for further research in this area.