Coronary artery aneurysms after angioplasty and atherectomy

Spontaneous disappearance of coronary pseudoaneurysm due to coronary artery perforation following percutaneous coronary intervention

In recent years, while therapeutic outcome after percutaneous coronary intervention is improving due to the introduction of drug-eluting stent and device development, procedure-related complications including coronary perforation may ineluctably occur though at low-frequency, even if careful manipulations are performed under IVUS guidance. Meanwhile, coronary pseudoaneurysm subsequent to coronary perforation is one of the complications at chronic phase infrequently experienced following percutaneous coronary intervention. To date, the incidence and natural history of pseudoaneurysm following coronary artery perforation remain unclear. We experienced a case with coronary pseudoaneurysm developed 2 weeks after Ellis II-type coronary artery perforation which spontaneously disappeared 4 months later. As the mechanism of disappearance, thrombotic occlusion was confirmed upon intravascular ultrasound.

A rare case of giant coronary artery aneurysm in the context of multiple arterial aneurysms

INTRODUCTION

Whilst the incidence of CAA has been reported as up to 5%, giant CAA (>2cm) is rare.

PRESENTATION OF CASE

We present a rare case of 3cm×4cm giant coronary artery aneurysm (CAA) in the context of aorto-iliac aneurysmal disease, treated by staged open surgical repair.

DISCUSSION

Abdominal aortic aneurysm (AAA) and CAA share risk factors and aetiological mechanisms, therefore should be considered, particularly when CAA is diagnosed in the first instance.

CONCLUSIONS

Surgical intervention for diagnosed giant CAA appears to be the treatment of choice in the reported literature, with the order of intervention when AAA co-exists remaining a point for debate.

Treatment of left anterior descending artery aneurysm

Coronary artery aneurysms (CAAs) are rare and their management is controversial. Their incidence varies from 1,5% to 5% of the coronary angiographies, with predilection of the right coronary artery. Unruptured coronary aneurysms are often silent and may remain undiagnosed. The etiology can be either congenital or acquired. We describe a case of a left anterior descending artery (LAD) aneurysm treated with an off-pump surgical revascularization with a LIMA to LAD without exclusion or ligature of the aneurysm.

Vascular Behçet's disease with coronary artery aneurysm

A 33-year-old man with a 4-year history of Behçet's disease was hospitalized with acute myocardial infarction. Percutaneous coronary intervention (PCI) treated 99% stenosis of the right coronary artery but follow-up coronary arteriography clearly revealed a coronary artery aneurysm (CAA) at the lesion proximal to the PCI site and intravascular ultrasound confirmed that it was a true aneurysm. We speculated that Behçet's disease might be involved in coronary lesion, especially in CAA formation. We decided to increase the dose of prednisolone and to add warfarin. The size of the CAA was not altered after 6 months.

Treatment of coronary artery aneurysms by percutaneous sealing with bovine-pericardium-covered stents

The clinical significance of coronary artery aneurysms is briefly discussed. Until recently, surgical excision was the only treatment available. Single-case reports have documented aneurysm exclusion with vein-covered stents using 10 or 11 F. guiding catheters. This paper reports four patients with coronary artery aneurysms which were successfully excluded with the use of a novel pericardium-covered stent which is less invasive and shortens procedure time compared with the use of an autologous vein-grated stent and can be deployed using 8 F. or 9 F. guiding catheters. Short-term (five- to eight-month) clinical follow-up has been event-free in all patients, and in three patients six-month follow-up angiography has shown insignificant luminal loss.

Surgical repair of coronary artery aneurysm after percutaneous coronary intervention

Two cases of coronary artery aneurysm after percutaneous coronary intervention are presented. In both cases, follow-up coronary angiography revealed an expanding saccular aneurysmal formation and restenosis or a new lesion. Consequently, surgical repair and revascularization were indicated. The intraoperative angioscope was used to identify the aneurysm, which had not been visible on the heart surface in one case. Its optic fiber light was a useful guide, but little information was obtained from direct vision because of the small caliber of the angioscope. Plication of the aneurysm and bypass grafting distal to the aneurysm were performed. A whitish and thick-walled aneurysm was easily found in one case, in which ligation of the aneurysm was attempted with added distal bypass. The postoperative course was uneventful in both cases, and follow-up angiography showed disappearance of the aneurysm with patent grafts. There was a fragile thrombus inside both the aneurysmal sacs, which might have caused myocardial infarction and, therefore, justified the surgical repair of the aneurysm with concomitant revascularization.

Multiple coronary artery aneurysms combined with abdominal aortic aneurysm

Coronary artery aneurysm (CAA) is defined as coronary dilatation which exceeds the diameter of a normal adjacent segment or the diameter of the patients's largest coronary vessel by as much as 1.5 times. It is an uncommon pathology with a frequency of 1-4% in routine autopsies or coronary angiographies. Atherosclerosis plays an important role in the development of CAA, and it may be a predominant cause in the majority of patients. However, the timing of surgical intervention and the treatment options for CAA are still controversial. In this report, we present a patient who had multiple CAAs of all main coronary arteries and abdominal aortic aneurysm. Different treatment modalities and indications are also discussed.

Vascular remodeling and the local delivery of cytochalasin B after coronary angioplasty in humans

OBJECTIVES

This study sought to determine the safety, feasibility and outcome of local delivery of cytochalasin B at the site of coronary angioplasty.

BACKGROUND

Previous failures in the pharmacologic prevention of restenosis may have been related to inadequate dosing at the angioplasty site as a result of systemic drug administration. Alternatively, although previous experimental protocols have typically targeted control of excess tissue growth (intimal hyperplasia), it now appears that overall arterial constriction (vascular remodeling) is the major contributor to late lumen loss. Cytochalasin B inhibits the polymerization of actin and has proved to be a potent inhibitor of vascular remodeling in animal models.

METHODS

In this phase I, multicenter, randomized, controlled trial, cytochalasin B (or matching placebo) was administered to the site of a successful balloon angioplasty using a microporous local delivery infusion balloon.

RESULTS

The rate of drug delivery at a constant infusion pressure varied significantly from patient to patient (range 1.7 to 20.2 ml/min), perhaps related to a variable constricting effect of the atherosclerotic plaque on the infusion balloon. The minimal stenosis diameter after the procedure was slightly better in the active drug group (1.86 +/- 0.44 vs. 1.49 +/- 0.63 mm, p < 0.03), but this difference was not seen at four to six weeks. Although the study was not powered for clinical outcomes (n = 43), the combined end point (death, nonfatal infarction or repeat revascularization) was encountered in 20% of the patients receiving cytochalasin B and in 38% of the patients receiving placebo. Clinical restenosis occurred in 18% of the treatment group and 22% of the placebo group. There were no significant differences between groups in biochemical or electrocardiographic variables.

CONCLUSIONS

Cytochalasin B can be safely administered by local delivery after successful coronary angioplasty and warrants further study of its efficacy in reducing restenosis.

Coronary artery aneurysm after stent implantation

A coronary artery aneurysm that developed 6 months after coronary stent implantation in the left anterior descending artery, was treated by double coronary artery bypass grafting due to restenosis of the affected vessel and progression of right coronary artery stenosis. Although the poststenting aneurysm initially remained postoperative angiography showed that it had disappeared. In addition to thrombotic occlusion, another mechanism behind its disappearance may be that geometric changes of the implanted stent caused by heart retraction during surgery closed the entrance to the aneurysm.

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.

Delayed development of a coronary artery pseudoaneurysm after angioplasty

One month after a successful angioplasty, one of our patients developed a new aneurysm in the right coronary artery (RCA). The aneurysm was characterized as a pseudoaneurysm by the use of intravascular ultrasound (IVUS). A stenosis that was not well seen by angiography was better depicted by IVUS. Both the pseudoaneurysm and the stenosis were successfully treated with a second angioplasty and stenting with a covered stent. Delayed development of pseudoaneurysms after dissection is an uncommon, but possible complication after angioplasty. In this case IVUS was useful for accurate characterization of the aneurysm. The use of covered stents may become a clinically useful method for treating coronary pseudoaneurysms.

Successful treatment of a ruptured mycotic coronary artery aneurysm

Documented mycotic aneurysms of the coronary arteries are unusual, and antemortem identification of such an aneurysm is rare. We present the case of a patient who had successful management of a ruptured mycotic aneurysm of a coronary artery.

Development of coronary aneurysm after cutting balloon angioplasty: assessment by intracoronary ultrasound

We report the case of a coronary aneurysm observed 6 mo after cutting balloon angioplasty complicated by a mild perforation. Intravascular ultrasound allowed characterization of the malformation as a true aneurysm. The clinical course was uneventful.

Coronary artery aneurysm rupture mimicking dissection of the thoracic aorta

Acute dissection of the ascending aorta may present with chest pain and haemopericardium. The following case illustrates an unusual differential diagnosis: rupture of a very large coronary artery aneurysm, diagnosed by transoesophageal echocardiography.

Repair of a coronary artery aneurysm by implantation of a coronary stent

A 67-year-old patient developed a third restenosis with coronary artery aneurysm of the left anterior descending artery after two previous percutaneous transluminal coronary angioplasty (PTCA) procedures and one previous combined excimer-laser/balloon angioplasty. The stenosis was successfully dilated by conventional balloon technique and the aneurysm was excluded by implantation of a Palmaz-Schatz stent. Follow-up examination after 6 months revealed normal coronary artery perfusion without restenosis, whereas the aneurysm remained occluded. This case demonstrates, that stenting of a coronary artery aneurysm may be a successful method for a permanent occlusion.

Congenital and Atherosclerotic (Acquired) Coronary Artery Aneurysms: Coronary Angiographic and Morphologic Observations in 10 Patients

Coronary angiographic observations in 10 patients with coronary artery aneurysms (CAAs) are reported. Four patients had atherosclerotic (acquired) and six had congenital CAAs. The mean age of patients with acquired CAAs was higher (64.7 years) compared with the congenital group (53.2 years). Ipsilateral myocardial infarction (MI) occurred in three of four patients with acquired CAAs but MI was not located on the same side as the aneurysm-bearing coronary artery (contralateral) in two patients with the congenital variety. In the patients with congenital CAAs, an aneurysm predilection site was observed in the proximal portion of the aneurysm-bearing vessel. Dual and multiple aneurysms were more common in the acquired CAAs. Although congenital CAAs were sizeable, the small-sized atherosclerotic CAAs developed complications more frequently. During an average follow-up of 7.9 years, only one patient died of a noncardiac cause and another developed recurrent uncomplicated non-Q wave lateral MI. Both subjects had atherosclerotic CAAs. In our series, no rupture or sudden death occurred. Coronary artery bypass grafting (CABG) was performed in three patients with acquired and in one patient with congenital CAAs. In the latter patient, simultaneous ligation of the congenital aneurysm associated with a coronary arteriovenous fistula was performed. Regarding antiplatelet and anticoagulant policy for the whole group, three patients were on aspirin, four were on acenocoumarol, and in another three subjects with congenital CAAs, a medical regimen was followed. Larger series, however, are required in order to elucidate further angiographic characteristics of acquired vs congenital CAAs.

Percutaneous closure of a coronary aneurysm with a vein-coated stent

Coronary artery aneurysm is a rare but recognized complication following percutaneous intervention. We report the formation of such an aneurysm after recanalization with Excimer laser wire of a chronic totally occluded left anterior descending coronary artery and stent implantation and its subsequent treatment using an autologous vein graft-coated stent.

Coronary artery aneurysm repaired with saphenous vein patch plasty

The presence of atherosclerotic coronary artery aneurysms is not always considered to be an operative indication. However, progressively expanded coronary artery aneurysms may have the potential for complications such as rupture or embolism. We present a case of successful repair of a coronary artery aneurysm located above the first septal perforator in the left anterior descending coronary artery using a saphenous vein patch and simultaneous construction of a right gastroepiploic artery graft to the occluded right coronary artery. Follow-up angiography at 6 months after operation revealed complete disappearance of the aneurysm with no luminal stenosis and a preserved large septal branch. The right gastroepiploic artery graft was also found to be widely patent.

Giant coronary artery pseudoaneurysm causing pulmonary artery obstruction: a rare complication of coronary bypass surgery--a case report

The authors report the diagnosis and successful management of a 57-year-old man with right ventricular outflow tract obstruction from a large pseudoaneurysm of the left anterior descending coronary artery 5 years after he had undergone redo coronary artery bypass grafting.

Acute myocardial infarction caused by thrombotic occlusion of a coronary aneurysm

We encountered an unusual case of acute myocardial infarction due to obstruction of a coronary aneurysm in a 38-year-old Japanese man. Although thrombolysis and rescue percutaneous transluminal coronary angioplasty, performed in the acute phase, did not result in recanalization, serial angiography and intravascular ultrasonography showed spontaneous recanalization and partial thrombosis within the aneurysmal segment during 3 months.

Coronary artery aneurysm: a review

Coronary artery aneurysm is defined as coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. This is an uncommon disease which has been diagnosed with increasing frequency since the advent of coronary angiography. The incidence varies from 1.5% to 5% with male dominance and a predilection for the right coronary artery. Atherosclerosis accounts for 50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture and vasospasm. The natural history and prognosis remains obscure. Controversies persist regarding the use of surgical or medical management. The authors recommend surgery based on the severity of associated coronary stenosis rather than the mere presence of aneurysm. Medical therapy is indicated for the majority of patients and consists of antiplatelet and anticoagulant medication.

Percutaneous transcatheter repair of a coronary aneurysm using a composite autologous cephalic vein-coated Palmaz-Schatz biliary stent

We describe a novel percutaneous transcatheter technique using an autologous vein graft-coated Palmaz-Schatz stent for the treatment of a coronary aneurysm. This technique avoids the procedural risks that are currently associated with surgical repair with revascularization or spring coil embolization in the treatment of coronary aneurysm.