Coronary artery aneurysm formation following PTCA

Coronary anomalies: left main coronary artery aneurysm

Coronary artery aneurysm is one of the rarest anomalies that we see in our medical practice and they are mostly associated with obstructive lesions due to atherosclerotic changes. Management of these aneurysm patients (conservative or surgical repair) usually depends on obstructive lesions and associated symptoms. We are presenting a case of left main aneurysm measuring around 14 × 28 mm with other obstructive leisons. It was treated with surgical repair in view of obstructive lesions and symptoms.

Late giant coronary aneurysm associated with a fracture of sirolimus eluting stent: a case report

A 73-year-old female underwent percutaneous coronary intervention (PCI) because of stable angina. An elective PCI for the RCA lesion was first performed with deploying sirolimus eluting stents (SES). Three weeks later, PCI was also provided in the residual LAD lesion. Eight months later, she presented with new angina. CAG revealed an in-stent restenosis in the mid LAD and a large eccentric saccular coronary aneurysm (17 mm x 9 mm) at the proximal RCA. Intravascular ultrasound (IVUS) showed absence of stent struts around the orifice of aneurysm, which suggested a fracture of SES stent. The entry of coronary aneurysm was finally sealed with a polytetrafluoroethylene-covered stent. This report documented a rare case of late giant coronary artery aneurysm associated with a fracture of SES.

Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction

We describe the occurrence of a localized saccular pseudoaneurysm in a 69-year-old patient 2 weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. The therapy of perforations requires prolonged balloon inflations, perfusion balloons, covered stents, or surgery. Coronary peudoaneurysm formations are rare; their therapy requires covered stents or surgery. Cathet. Cardiovasc. Intervent. 47:341-346, 1999.

Giant left main coronary artery aneurysm in association with severe atherosclerotic coronary disease

Aneurysms of the coronary arteries occur in 1.5-4.9% of coronary angiograms. Only a few cases of a giant aneurysm of the left main coronary artery in conjunction with severe atherosclerotic coronary disease have been reported. This report details the exceptional case of a 72-year-old patient with a giant "true saccular" aneurysm branched on the left main coronary artery. The development of an aneurysmal dilatation in conjunction with progression of coronary arteriosclerosis, observed from two different angiographic studies at an interval of 25 years, is very illustrative for evolutive atherosclerotic heart disease. This finding may support the hypothesis that atherosclerosis may be the common etiology for coronary aneurysmal dilatation.

Spontaneous regression of post-percutaneous transluminal coronary angioplasty aneurysm

We report a case of a 67-year-old male with spontaneous regression of post-percutaneous transluminal coronary angioplasty (PTCA) aneurysm. This case substantiates the benign prognosis of post-PTCA aneurysms.

Assessment of coronary artery aneurysms with multiplane transesophageal echocardiography

Coronary artery aneurysms are rare and may be difficult to detect clinically. Multiplane transesophageal echocardiography provides numerous imaging planes that may improve the assessment of coronary aneurysms and act as an adjunct to standard angiography. Five patients with angiographically detected coronary aneurysms were studied with multiplane transesophageal echocardiography and Doppler flow imaging. Transesophageal echocardiography was successful in identifying the size and characteristics of the coronary aneurysms. Doppler ultrasound identified markedly increased flow velocity in a patient with a coronary arteriovenous fistula and decreased coronary flow velocity in two patients with aneurysmal coronary arteries and intracoronary thrombus. Multiplane transesophageal echocardiography is a useful, noninvasive method of assessing coronary artery aneurysms and may act as an adjunct to angiography in identifying fistula anastomosis.

Coronary artery aneurysms after angioplasty and atherectomy

Coronary artery aneurysm formation after percutaneous transluminal coronary angioplasty and directional coronary atherectomy is unusual. We report the case of a left anterior descending coronary artery aneurysm that formed in such a patient. The left anterior descending coronary artery was bypassed and the aneurysm was plicated with the aid of coronary angioscopy. The English-language medical literature on the topic of coronary artery aneurysms is reviewed.

Angiographic-pathologic correlations after elective percutaneous transluminal coronary angioplasty

BACKGROUND

The local effect of coronary angioplasty is evaluated on the basis of postangioplasty angiograms. Smooth-walled dilation is considered to represent minimal or no injury, whereas intraluminal haziness corresponds with wall laceration. This study correlates the preangioplasty and postangioplasty angiograms with the histopathology of the target sites.

METHODS AND RESULTS

The study includes 12 patients, each undergoing an elective procedure, and covers 19 angioplasty sites. Smooth-walled dilation and intraluminal haziness were not mutually exclusive. The angiograms were interpreted as smooth-walled dilation (n = 3), smooth-walled dilation with intraluminal haziness (n = 4), intraluminal and extraluminal haziness (n = 5), extraluminal dissection (n = 5), spiraltype dissection (n = 1), and aneurysm (n = 1). The histology of the arterial segments revealed wall laceration in all. Smooth-walled dilation without intraluminal haziness correlated with laceration limited to the intima in two, but with medial injury in one. Smooth-walled dilation with intraluminal haziness correlated with laceration limited to the intima in two and with medial injury in two. Intraluminal and extraluminal haziness corresponded with extensive laceration with deep involvement of the media in each. Extraluminal dissection correlated with a dissection along the shoulder area of the plaque, creating a broad-based flap. The spiral-type dissection corresponded with a true dissection into the plaque-free media. The aneurysm correlated with partial washout of an atherosclerotic plaque.

CONCLUSIONS

The angiographic image of intraluminal and extraluminal haziness indicates extensive medial laceration. Smooth-walled dilation, with or without intraluminal haziness, is not a reliable indicator. The study emphasizes the need to reconsider the interpretations of postangioplasty coronary angiograms.

Contained rupture following percutaneous transluminal coronary angioplasty: long-term outcome

Coronary artery aneurysm formation can occur as a complication of balloon angioplasty. We present a case of a contained rupture of the left circumflex artery following angioplasty which resulted in an unusual pseudoaneurysm on angiography at 3-year follow-up.

Relation of deep arterial resection and coronary artery aneurysms after directional coronary atherectomy

OBJECTIVES

The aims of this study were to document the frequency of coronary artery aneurysm formation in patients undergoing directional coronary atherectomy and to determine the relation of such aneurysms to the depth of arterial resection.

BACKGROUND

Deep arterial injury is relatively frequent with the use of directional coronary atherectomy, but the potential for subsequent coronary artery aneurysm formation is unknown.

METHODS

Results in a consecutive series of 64 successfully treated patients (a total of 69 lesions; mean angiographic follow-up at 5 months) treated with directional coronary atherectomy were retrospectively analyzed with use of quantitative angiographic and histologic data.

RESULTS

Coronary aneurysms (ratio of dilated vessel segment to the adjacent reference segment > 1.2:1) occurred in seven patients (10%). The only significant clinical correlate of aneurysm formation was a relatively shorter duration of angina. There were no significant preprocedural angiographic predictors of aneurysms, although 6 (86%) of the 7 aneurysmal lesions arose from restenosis lesions compared with 30 (48%) of 62 lesions with no subsequent aneurysm development (p = 0.06). Histopathologic examination of 414 specimens from 68 treated lesions showed no significant difference in the occurrence of subintimal resection (media +/- adventitia) between those with and without subsequent aneurysm (29% vs. 22%). Media alone was found in 14% of specimens from lesions that later became aneurysmal versus 15% of those that did not; adventitial resection was found in 14% and 7% of specimens, respectively (p = 0.08), with relatively more adventitia per specimen from those with aneurysm (55% vs. 30% without aneurysm, p = 0.08).

CONCLUSIONS

Aneurysms occur relatively frequently after directional coronary atherectomy. Although there was no statistically significant correlation with the depth of arterial resection, the evidence from this study suggests that the role of adventitial resection in the occurrence of late aneurysm development should be explored further.

Long-term results of directional coronary atherectomy: predictors of restenosis

OBJECTIVES

This study was performed to obtain better understanding of the long-term clinical efficacy of directional coronary atherectomy.

BACKGROUND

Although this procedure yields favorable acute results, its acceptance has been limited by the perception that late results (that is, freedom from restenosis) are no better than those of conventional angioplasty.

METHODS

A total of 225 atherectomies performed in 190 patients between August 1988 and July 1991 were examined. Minimal lumen diameter of the treated segments was measured on angiograms obtained before, after and 6 months after intervention.

RESULTS

Although most lesions (97%) had one or more characteristics predictive of unfavorable short- or long-term results after conventional angioplasty, atherectomy was successful in 205 lesions (91%) with a mean residual stenosis of 7 +/- 16%. After subsequent balloon angioplasty in 16 unsuccessful atherectomy attempts, procedural success was 98%. There were no deaths or Q wave myocardial infarctions, and one patient (0.5%) underwent emergency bypass surgery. Six-month angiographic follow-up was obtained in 77% of the eligible patients. The overall angiographic restenosis rate was 32%. Predictors of a lower restenosis rate included a postprocedure lumen diameter > 3 mm (24% vs. 39%, p = 0.047), serum cholesterol < or = 200 mg/dl (18% vs. 40%, p = 0.018) and recent myocardial infarction (16% vs. 37%, p = 0.034). Life-table analysis showed a 2% mortality rate and a 26% incidence of other events (myocardial infarction, repeat revascularization) within the 1st year. The annual 5% mortality rate and 7% incidence of other events during years 2 and 3 were related in large part to the existence or progression of disease at other locations.

CONCLUSIONS

Six-month angiographic follow-up of patients who underwent directional coronary atherectomy during the 1st 3 years of our experience shows an overall restenosis rate of 32%, with lower rates in patients with a postatherectomy lumen diameter > or = 3 mm, cholesterol level < or = 200 mg/dl or a recent myocardial infarction. Few if any events relating to the site of atherectomy developed after the 1st year of follow-up.

Coronary aneurysms: a case report and review

This case report describes a large coronary aneurysm and poses questions regarding management. The discussion that follows addresses what is known about the natural history of and options for management of coronary aneurysms.

Left main coronary artery aneurysm following percutaneous transluminal angioplasty: a report of a case and review of the literature

Since its introduction in 1977, the number of PTCAs and its indications have grown. Along with more frequent usage, newer complications have been reported. Aneurysm of left main coronary artery is rare. This report describes the formation of a new non-obstructing aneurysm in the left main coronary artery after PTCA of left circumflex artery. The patient has had 7 yr of follow-up with a benign clinical course.

Coronary aneurysms after stent placement: a suggestion of altered vessel wall healing in the presence of anti-inflammatory agents

Coronary aneurysms are rare after conventional angioplasty and have not been reported after coronary stenting. Coronary artery stent sites were examined by follow-up angiography at a median of 4 months in 29 patients who received the Cook stent (Gianturco-Roubin) for acute coronary closure. Nineteen patients were treated with glucocorticoids administered intravenously or orally, or both, with or without colchicine and results were compared with those in 10 patients who were treated with neither agent. Standard therapy for all patients included routine administration of aspirin and heparin before and warfarin sodium (Coumadin) and aspirin after stent placement. Most patients also received dipyridamole and lovastatin during the follow-up period. Compliance with medications was confirmed by telephone conversation with each patient. Six (32%) of the 19 stented arteries showed evidence of coronary artery aneurysm, defined as expansion of the lumen outside the margins of the stent. None of the patients in the control group (who did not receive steroids or colchicine) developed aneurysm. This pattern of altered vascular healing in stented coronary segments appears to be due to the addition of multiple anti-inflammatory drugs rather than to stent presence alone. This observation demonstrates the possibility of medical impairment of normal vascular remodeling after acute injury and stent placement, which may be of benefit in designing future trials on restenosis.

Coronary artery aneurysms--a case study and literature review

Coronary artery aneurysms are detected with increasing frequency owing to the advent of coronary angiographies. Although most patients with coronary artery aneurysms are asymptomatic, manifestations of myocardial ischemia may occur. The case described herein serves as a basis for a discussion of the pathogenesis, clinical manifestations, detection, and treatment of coronary artery aneurysms.

Predictability and prognosis of PTCA-induced coronary artery aneurysms

The natural history of coronary aneurysms, defined as local dilatations exceeding the diameter of the normal adjacent vessel segments by at least 1.5 times, is not significantly different from the natural history of nonaneurysmal coronary disease. However, little is known about the prognosis of percutaneous transluminal coronary angioplasty (PCTA)-induced coronary aneurysms. Therefore, we investigated the occurrence and the medium long-term prognosis of such aneurysms in 728 patients who, after successful PTCA, underwent repeat coronary angiography at mean 4.5 months post-PTCA. A coronary aneurysm at the site of PTCA ws noted in 3.9% of patients (n = 28). Of the potentially predictive factors analyzed, only a coronary dissection at the time of PTCA had statistically significant influence. The long-term prognosis of PTCA-induced coronary aneurysms was excellent. One patient underwent (unrelated) cardiac surgery, all other 27 patients remained eventfree. We conclude that the same benign nature of coronary aneurysmal disease holds true for those aneurysms that develop after PTCA.

Coronary atherectomy. Clinical, angiographic, and histological findings and observations regarding potential mechanisms

Between August 5, 1988 and August 1, 1989, we attempted percutaneous directional coronary atherectomy of 76 lesions, including 42 primary lesions and 34 restenosis lesions that developed after one or more prior interventions. The procedure was successful in 67 lesions (88%), with a decrease in diameter stenosis from 80 +/- 11% to 5 +/- 15% after atherectomy (p less than 0.01). One or more complications occurred in six patients (9%), including non-Q wave myocardial infarction (three patients, 4.5%), femoral arterial injury requiring surgical repair (two patients, 3%), and proximal dissection leading to emergency bypass surgery (one patient, 1.5%). Despite these favorable acute results, the 6-month lesion restenosis rate was 30% by life-table analysis. Light microscopy of retrieved tissue revealed atherosclerotic plaque in 94%, media in 67%, and adventitia in 27%. Intimal proliferation was present in 97% of the restenosis lesions but was also evident in 33% of primary lesions. Tissue weight from 27 lesions averaged 18.5 mg (range, 5.8-45.1 mg), which is not adequate to explain the entire angiographic improvement. Thus, part of the improvement in lumen diameter appears to be due to mechanical dilatation rather than to tissue removal alone. Atherectomy can predictably treat selected coronary lesions with overall safety comparable to that of conventional balloon angioplasty, although the procedure as currently performed does not derive all of its benefit from tissue removal and does not appear to prevent restenosis.

Coronary artery aneurysm formation following percutaneous transluminal coronary angioplasty: treatment of associated restenosis with repeat percutaneous transluminal coronary angioplasty

Restenosis following coronary angioplasty can usually be treated effectively and safely by repeated angioplasty. However, the presence of a complex lesion morphology may bias the clinician away from angioplasty toward either recommending bypass surgery or continuing medical therapy alone in spite of recurrence of the symptoms which were sufficient indication for the initial angioplasty. One type of complex morphology at the site of the restenosis is due to the presence of a focal, eccentric aneurysmal dilatation similar in appearance to a saccular aneurysm. In two previously reported cases in the literature both were referred to bypass surgery. We report eight additional cases including the use of repeat successful angioplasty in six of the cases in spite of the potential problems posed by the complexity of the restenosed lesion. In addition, this case review suggests that this type of complex lesion morphology with restenosis may be more common when the initial angioplasty was associated with deep arterial injury, as in patients whose initial angioplasty was done in an infarct-related vessel or was associated with evidence of a large dissection.

Coronary arterial aneurysms after percutaneous transluminal coronary angioplasty--a not uncommon finding at elective follow-up angiography

Five coronary arterial aneurysms were found in 4 of 80 (5%) patients who underwent elective coronary arteriography 6 months after successful percutaneous transluminal coronary angioplasty. None of them was present immediately after dilatation. All patients had been suffering from stable angina before angioplasty, while no case had recurrent angina or definite angiographic restenosis at the 6-month follow-up. Quantitative coronary angiography was performed in all angiograms. The coronary aneurysms only developed in the dilated portions (4 in left anterior descending and 1 in an intermediate branch of the left coronary artery): their diameter ranged from 3.1 to 4.4 mm, and their length from 2.2 to 4.9 mm. The ratio between the aneurysm diameter and the coronary arterial diameter (aneurysm: artery ratio) varied from 1.15 to 1.91 (mean 1.47). No significant clinical or technical differences were found between patients who developed aneurysm after angioplasty, and patients who did not. On the other hand, 4 of the 5 patients who developed aneurysm had angiographic evidence of "non-pathologic" dissection immediately after balloon dilatation. Moreover, the ratio between the measured angiographic diameters of the balloon (at maximal inflating pressure) and of the coronary artery selected for the procedure showed that the balloon was mildly oversized (balloon: artery ratio ranging from 1.10 to 1.37, mean 1.28) in all cases with aneurysm except the only 1 in whom dissection did not occur. In conclusion, aneurysm formation after coronary angioplasty is not infrequent in our experience: balloon size and wall dissection seem to be the major factors related to this event.

Angiographic features in the infarct-related artery after intracoronary urokinase followed by prolonged anticoagulation. Role of ruptured atheromatous plaque and adherent thrombus in acute myocardial infarction in vivo

To unravel sequential morphological features in infarct-related coronary arteries (IRCA), we performed coronary angiography (CAG) before, during, and immediately after intracoronary urokinase infusion in 43 consecutive patients. After 1 month of rigorous anticoagulation by intravenous heparin and subsequent oral warfarin or after the same period of treatment by antiplatelet agents, we repeated CAG in all patients except for one, who died 6 days after thrombolytic therapy. Thirty-two IRCAs were totally occluded, and 11 were severely occluded at baseline. With recanalization and/or reduction in luminal narrowing at the site of the occlusion by progressive removal of the overlying thrombus and plaque content, we recognized the development of extraluminal contrast pooling in an ellipsoid shape (type A), single or paired linear radiolucency(ies) with or without outpouching (type B), and definite outpouching (type C). The development of type A, B, and C lesions occurred in 4, 6, and 0 IRCAs immediately after thrombolytic therapy and in 0, 18, and 3 IRCAs 1 month later, respectively. Throughout the study, at least one of type A-C lesions developed in 23 of 43 (53.5%) IRCAs. Lesion development proceeded from total or severe occlusion to type A, then to type B or C, both accompanied by progressive reduction in luminal narrowing and frequent enlargement of outpouching. A postmortem study in one patient whose CAG immediately after thrombolytic therapy was interpreted as a type B lesion demonstrated a ruptured plaque with paired ridges. Serial observations in vivo indicate that many IRCAs are associated with a complex underlying spatial structure, probably composed of some part of ruptured atheromatous plaque with or without adherent thrombus. Recognition and identification of such complex structures beneath the accumulated thrombus are of great importance in both CAG interpretation and elucidation of the pathophysiological sequence of acute myocardial infarction in vivo and may enable prevention or more effective therapy of acute coronary events.