Clinical outcomes of patients with coronary artery aneurysm after the first generation drug-eluting stent implantation

Coronary Artery Aneurysms, Arteriovenous Malformations, and Spontaneous Dissections-A Review of the Evidence

BACKGROUND

Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management.

METHODS

A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs.

RESULTS

CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting.

CONCLUSIONS

Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations.

Coronary Artery Aneurysm: Its Evaluation in a 27-Year-Old Female Patient, Prognosis, and Suggested Treatment Strategies

Coronary artery aneurysm (CAA) is characterized by a localized dilation of one or more of the coronary arteries with multiple etiologies, including congenital, acquired, or connected to auto-inflammatory diseases with multiple shapes and classifications. It is usually diagnosed incidentally during coronary imaging and can have variable clinical outcomes, ranging from asymptomatic to sudden cardiac death with a generally poor prognosis. Management of this condition faces a clinical dilemma due to the lack of clear guidelines or randomized trials. Treatment should be individualized based on symptoms, shape, and comorbidities. Herein, we present the case report of a 27-year-old female patient with no prior medical conditions. However, she presented with palpitations, and a compressive mass located over the right atrium was identified in the patient. After undergoing cardiac catheterization and coronary scanning, a giant aneurysm of the sinoatrial branch was detected with an aneurysmal left main that was retrieved surgically with good recovery and postoperative course.

Coronary artery aneurysms: Comprehensive review and a case report of a left main coronary artery aneurysm

Coronary artery aneurysms (CAAs) are rare anatomical disorders of the coronary arteries. Atherosclerosis and Kawasaki disease are the principal causes of CCAs, while other causes including genetic factors, inflammatory arterial diseases, connective tissue disorders, endothelial damage after cocaine use, iatrogenic complications after interventions and infections, are also common among patients with CAAs. Although there is a variety of non-invasive methods including echocardiography, computed tomography, and magnetic resonance imaging, coronary angiography remains the gold standard diagnostic method. There is still no consensus about the most appropriate therapeutic strategy. Medical therapy including antiplatelets, anticoagulants, statins and ACEs are preferred either in patients with atherosclerosis, inflammatory status and stable CAAs, while percutaneous or surgery interventions are usually applied in patients with acute coronary syndrome due to a CAA culprit, obstructive coronary artery disease or large saccular aneurysms at a high risk of rupturing.

Coronary Artery Aneurysms as a Cause of Acute Coronary Syndrome Presentation - A Focused Review

Coronary artery aneurysms (CAA) are defined as a dilation of a coronary vessel greater than 1.5 times the diameter of a local reference vessel. While CAAs tend to be incidental findings on imaging, they result in complications, such as thrombosis, embolization, ischemia, arrhythmias, and heart failure. Among symptomatic cases, chest pain has been the most common manifestation of CAAs. This necessitates an understanding of CAAs as a cause of acute coronary syndrome (ACS) presentation. However, due to the unclear pathophysiology of CAAs and their variable presentation complicated by similar ACS conditions, there is no clear strategy for CAA management. In this article, we will discuss the contribution of CAAs to ACS presentations and review the current management options for CAAs.

Coronary artery aneurysm: A review

Coronary artery aneurysm (CAA) is a clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold diameter of the adjacent normal segment. Atherosclerosis is the main cause in adults and Kawasaki disease in children. CAA is a silent progressive disorder incidentally detected by coronary angiography, but it may end with fatal complications such as rupture, compression of adjacent cardiopulmonary structures, thrombus formation and distal embolization. The pathophysiological mechanisms are not well understood. Atherosclerosis, proteolytic imbalance and inflammatory reaction are involved in aneurysmal formation. Data from previously published studies are scarce and controversial, thereby the management of CAA is individualized depending on clinical presentation, CAA characteristics, patient profile and physician experience. Multiple therapeutic approaches including medical treatment, covered stent angioplasty, coil insertion and surgery were described. Herein, we provide an up-to-date systematic review on the pathophysiology, complications and management of CAA.

Multi-Vessel Coronary Artery Ectasia

Coronary artery ectasia is a relatively rare entity, especially when it involves the left main coronary artery. Furthermore, it is even more uncommon for such a disease process to involve multiple coronary arteries. Here we describe a case of a 78-year-old female who did not possess any of the common risk factors or vasculitic etiologies associated with coronary artery ectasia, who was found to have multi-vessel ectatic segments, including that of the left main coronary artery. This case illuminates the difficult decision making regarding stenting of the coronary arteries with ectatic segments and the decision to anticoagulate.

Coronary artery vasculitis: a review of current literature

Cardiac vasculitis is recognized as a heterogeneous disease process with a wide spectrum of manifestations including pericarditis, myocarditis, valvular heart disease and less frequently, coronary artery vasculitis (CAV). CAV encompasses an emerging field of diseases which differ from conventional atherosclerotic disease and have a proclivity for the younger population groups. CAV portends multiple complications including the development of coronary artery aneurysms, coronary stenotic lesions, and thrombosis, all which may result in acute coronary syndromes. There are several aetiologies for CAV; with Kawasaki's disease, Takayasu's arteritis, Polyarteritis Nodosa, and Giant-Cell Arteritis more frequently described clinically, and in literature. There is a growing role for multi-modality imaging in assisting the diagnostic process; including transthoracic echocardiography, cardiac magnetic resonance imaging, computed tomography coronary angiography, fluorodeoxyglucose-positron emission tomography and conventional coronary angiogram with intravascular ultrasound. Whilst the treatment paradigms fundamentally vary between different aetiologies, there are overlaps with pharmacological regimes in immunosuppressive agents and anti-platelet therapies. Interventional and surgical management are is a consideration in select populations groups, within a multi-disciplinary context. Further large-scale studies are required to better appropriately outline management protocols in this niche population.

A pebble clogging a river: a case report of thrombosed coronary aneurysmal ectasia

Background

Coronary artery ectasia (CAE) is a rare anomaly that can present at any age. Predisposing risk factors include Kawasaki disease in a younger population and atherosclerosis in the older generation. We present a unique case of the management of a young woman diagnosed with multivessel CAE with aneurysmal changes in the setting of acute coronary syndrome and subsequently during pregnancy.

Case summary

A 23-year-old woman presented with acute onset chest pain. Electrocardiogram revealed no ischaemic changes; however, troponin I peaked at 16 ng/mL (reference range 0–0.04 ng/mL). Echocardiogram showed apical dyskinesis with preserved left ventricular ejection fraction. Coronary angiography showed multivessel CAE along with significant thrombus burden in an ectatic lesion of the left anterior descending artery. Since the patient was haemodynamically stable, conservative management with dual antiplatelet therapy and anticoagulation was started. On follow-up, coronary computed tomographic angiogram illustrated resolution of the coronary thrombi and echocardiogram showed improvement to the apical dyskinesis. It was presumed that Kawasaki disease was the most likely aetiology of her disease. Subsequently the patient reported that, contrary to medical advice, she was pregnant, adding another layer of complexity to her case.

Discussion

Coronary artery ectasia can be discovered as an incidental finding or can present with an acute coronary syndrome. Management is challenging in the absence of randomized trials and large-scale data. Treatment options include medications, percutaneous intervention, and surgical revascularization. Close surveillance is required in these patients to assess progression of disease. Here we discuss treatment options during acute coronary syndrome and pregnancy.

Challenges and strategies in the management of coronary artery aneurysms

Coronary artery aneurysms (CAAs) are infrequent but not rare. Because of the lack of supportive data and a substantial knowledge gap in this field, clinicians are in a dilemma how to manage patients with coronary artery aneurysms. Most often, CAAs are discovered incidentally, while symptomatic patients present with diverse complications of unstable angina, myocardial infarction, arrhythmias, or sudden cardiac death. Therapeutical approaches consist of surgical procedure, percutaneous coronary intervention (PCI), and medical management. Because of the scarcity of randomized trials or large-scale data on symptomatic and asymptomatic patients with coronary artery aneurysms, the management of these patients poses considerable challenges for the cardiologists. This review summarizes the current literature, a proposed algorithm for the management of CAAs is highlighted in the text. In view of the majority of current proposal information based on small series of case reports or observational studies, an individualized therapeutic regimen should be on the basis of the location, expansion by time, morphology, complications, and etiologies of the coronary artery aneurysms, the clinical presentations, and the patient's characteristics.

Outcomes in Patients Fully Covered With Coronary Artery Aneurysm and Stenosis Lesion by Second Generation Drug-Eluting Stents After 1 Year

We evaluated the safety and efficacy of second-generation drug-eluting stents (DES) fully covering a coronary artery aneurysm (CAA) and stenosis lesion. Patients (n = 33) with CAA and stenosis lesion (>60%) were enrolled between January 2014 and December 2017. Baseline characteristics and biochemical variables were recorded during hospital admission. Changes in CAA resolution (the reduction on CAA size), minimal lumen diameter (MLD), and diameter stenosis (DS) were determined before, just after, and 1 year after percutaneous coronary intervention (PCI). After DES implantation, MLD and DS after PCI were improved compared with those before PCI (P < .01). Also, thrombolysis in myocardial infarction blood flow was significantly enhanced after PCI (P < .01). One year after PCI, maximal CAA diameter in patients with CAA and stenosis lesion was significantly reduced compared with those just after PCI (P < .01). Meanwhile, CAA resolution ratio in these patients were more than those just after PCI (P < .01). Furthermore, there was a significant reduction about CAA length in these patients (P < .01). Last, there were no clinical events (including cardiac death, myocardial infarction, and revascularization) in the study. Second-generation DES implantation fully covering CAA and stenosis lesion was safe and effective.

Uncommon Anatomic Predisposition to Myocardial Infarction: A Case of Coronary Artery Ectasia

Coronary artery ectasia (CAE) is a recognized cause of acute coronary syndrome (ACS), and can be associated with life-threatening complications, including thrombus formation with consequent distal coronary artery embolization. Several studies have demonstrated a higher incidence of cardiovascular adverse events and cardiac death in patients with CAE or coronary artery aneurysms compared to those without such abnormalities. Management of symptomatic CAE is similar to coronary artery disease (CAD), where guideline-directed medical therapy is indicated due to coexistence of CAD with acquired CAE. Percutaneous coronary intervention can be attempted; however, it is challenging, as it is associated with lower procedural success, higher rates of stent thrombosis, and repeat revascularization.

Bioresorbable scaffold implantation in STEMI patients: 5 years imaging subanalysis of PRAGUE-19 study

Background

Bioresorbable scaffold (BRS) Absorb™ clinical use has been stopped due to higher rate of device thrombosis. Scaffold struts persist longer than 2 years in the vessel wall. Second generation devices are being developed. This study evaluates long-term invasive imaging in STEMI patients.

Methods

PRAGUE-19 study is an academic study enrolling consecutive STEMI patients with intention to implant Absorb™ BRS. A total of 83 STEMI patients between December 2012 and March 2014 fulfilled entry criteria. Coronary angiography and optical coherence tomography at 5 year follow-up was performed in 25 patients.

Results

Primary combined clinical endpoint (death, myocardial infarction or target vessel revascularization) occurred in 12.6% during the five-year follow-up with overall mortality 6.3%. Definite scaffold thrombosis occurred in 2 patients in the early phase after BRS implantation. Quantitative coronary angiography after 5 years demonstrated low late lumen loss of 0.11 ± 0.35 mm with binary restenosis rate of 0%. Optical coherence tomography demonstrated complete resorption of scaffold struts and mean lumen diameter of 3.25 ± 0.30 and 3.22 ± 0.49 (P = 0.73) at baseline and after 5 years, respectively. Three patients developed small coronary artery aneurysm in the treated segment.

Conclusion

Invasive imaging results 5 years after BRS implantation in STEMI showed complete resorption of scaffold struts and stable lumen vessel diameter.

Trial registration ISRCTN43696201 (retrospectivelly registred, June 7th, 2019). https://www.isrctn.com/ISRCTN43696201.

Coronary Artery Aneurysm after Second-Generation Drug-Eluting Stent Implantation

PURPOSE

We evaluated the incidence, predictors, and prognosis of coronary artery aneurysm (CAA) after second-generation drug-eluting stent (DES) implantation.

MATERIALS AND METHODS

A total of 976 consecutive patients (1245 lesions) who underwent follow-up angiography after second-generation DES implantation were analyzed. Incidence and predictors of CAA were assessed, and clinical prognosis was compared with 34 cases of CAA after first-generation DES implantation using previous CAA registry data.

RESULTS

All 10 cases of CAA (0.80% per lesion) in 10 patients (1.02% per patient) were detected at follow up. Compared to lesions without CAA, those with CAA had greater involvement of the proximal segment (90% vs. 51%, p=0.014), a higher proportion of pre-intervention, a Thrombolysis in Myocardial Infarction score of 0 or 1 flow (80% vs. 16%, p<0.001), more chronic total occlusions (40% vs. 10%, p<0.001), and longer implanted stents (41.9±23.2 mm vs. 28.8±14.8 mm, p=0.006). As for CAA morphology, instances of CAA after second-generation DES were predominantly the single fusiform type (90%), whereas instances of CAA after first-generation DES were multiple saccular (47%) and single saccular (35%) types (p<0.001). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA after first-generation DES (15%), and no adverse events were observed in patients with CAA after second-generation DES over a median follow-up duration of 4.3 years (p=0.047, log-rank).

CONCLUSION

Although CAAs after second-generation DES implantation were detected at a similar incidence to that for CAAs after first-generation DES implantation, second-generation DES-related CAAs had different morphologies and more benign clinical outcomes versus first-generation DES-related CAAs.