Coronary artery aneurysms, insights from the international coronary artery aneurysm registry (CAAR)

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.

A rare case of diffuse ectasia in the coronary arteries and proximal aneurysm in the left anterior descending artery: A case report

INTRODUCTION

Coronary artery aneurysm is defined as dilatation of a segment of coronary artery, greater than 1.5 times the diameter of the largest normal coronary artery of the patient. Major cause of coronary artery aneurysm is coronary artery disease. Coronary artery aneurysm maybe an incidental finding during coronary angiography or it may present with symptoms including chest pain, myocardial infarction or even death.

CASE PRESENTATION

We present a rare case of a 59-year-old gentleman, who had, previously, underwent multiple left heart catheterizations and percutaneous coronary interventions. He presented to us with symptomatic diffuse ectasia of the coronary arteries with proximal aneurysm in the Left Anterior Descending Artery.

DISCUSSION

Coronary artery aneurysms are very rare with an incidence of about 0.02 %-0.04 % and a prevalence of 0.3 %-12 %. Right Coronary Artery is the principal site coronary artery aneurysms with a predominance of 83.8 %. The occurrence of multiple aneurysms is a very rare finding. About 73 % patients present with single aneurysms while only 27 % present with multiple aneurysms. Coronary artery aneurysms predispose to various complications including compression of the chambers, thrombosis and rupture.

CONCLUSION

From the presented case it can be concluded that even though, conservative management is available, surgical repair is the gold standard treatment, especially in the presence of multiple, symptomatic and large aneurysms in order to avoid fatal ischemic complications.

Aneurysms involving the coronary arteries in a neonate with neurofibromatosis 1

Aneurysmal coronary artery disease (ACAD) has been reported rarely in patients with neurofibromatosis type 1 (NF1), mostly in adults. We report on a female newborn affected by NF1 with ACAD disclosed during investigation for an abnormal prenatal ultrasound along with a review of the previously reported cases. The proposita had multiple café-au-lait spots and had no cardiac symptoms. Echocardiography, and cardiac computed tomography angiography confirmed aneurysms on the left coronary artery, left anterior descending coronary artery, and of the sinus of Valsalva. Molecular analysis detected the pathogenic variant NM_001042492.3(NF1):c.3943C>T (p.Gln1315*). Literature findings on ACAD in NF1 indicated that this mostly occurs in males, showing predilection for the development of aneurysms at the left anterior descending coronary artery, and manifesting predominantly as acute myocardial infarction, inclusively in teenagers, though it may be also asymptomatic as in our case. This report documents the first case of ACAD in a patient with NF1 diagnosed at birth, emphasizing that its early diagnosis is essential to prevent potential life-threatening events attributable directly to coronary lesions.

Giant right coronary artery aneurysm in a dominant right system

Giant coronary artery aneurysms (GCAAs) are unusual and extremely rare. Due to their rarity, there is a lack of data on managing GCAAs. A man in his 70s who presented with worsening shortness of breath and bilateral lower extremity oedema was found to have non-ST elevation myocardial infarction. Coronary angiography showed a tortuous Shepherd's crook right coronary artery with ectasia and a gigantic 4.5×4 cm saccular aneurysm in the mid-right coronary artery with limited flow to the distal vasculature. He subsequently underwent aneurysmal clipping and excision with coronary artery bypass grafting. GCAAs are usually silent and diagnosed incidentally but can also present with variable cardiac symptoms. Treatment options include medical management, percutaneous coronary angioplasty and surgery. As per limited available literature, surgical resection has shown favourable outcomes, especially in symptomatic GCAAs. The patient reported significant symptomatic improvement on the follow-up office visit.

ST-elevation myocardial infarction complicated by ventricular tachycardia revealing coronary artery ectasia: a case report

BACKGROUND

Coronary artery ectasia is a rare angiographic finding and results from a disease process that compromises the integrity of the vessel wall. Its prevalence ranges between 0.3% and 5% of patients undergoing coronary angiography (Swaye et al. in Circulation 67:134-138, 1983). Coronary artery ectasia in patients with ST-elevation myocardial infarction is associated with an increased risk of cardiovascular events and death after percutaneous coronary intervention.

CASE PRESENTATION

We report the case of a 50-year-old male Caucasian patient, admitted for ventricular tachycardia at 200 beats per minute hemodynamically not tolerated that was reduced by external electric shock. Electrocardiogram after cardioversion showed a sinus rhythm with anterior ST-elevation myocardial infarction. Thrombolytic therapy was chosen after exposure to dual antiplatelet therapy and heparin since the expected time to percutaneous coronary intervention was greater than 120 minutes from first medical contact and the patient presented within 12 hours of onset of ischemic symptoms. The electrocardiogram after thrombolysis showed the resolution of the ST segment. The echocardiogram showed a dilated left ventricle with severe dysfunction with left ventricle ejection fraction at 30%. Coronary angiography revealed non-obstructive giant ecstatic coronaries without any thrombus. A check-up to look for possible etiologies for coronary artery ectasia was carried out and returned normal. Since no etiology for coronary artery ectasia was found at the limit of available exams in our center, the patient was discharged with antiplatelet therapy (aspirin 100 mg once a day) and heart failure treatment with an indication for an implantable cardiac defibrillator.

CONCLUSIONS

Coronary artery ectasia in the context of acute myocardial infarction is a rare condition that may have dangerous complications, especially when an optimal treatment for ecstatic culprit vessels is still controversial.

Left Main Coronary Artery Aneurysm With Rare Quadfurcation Anatomy

Coronary artery aneurysms (CAAs) are found in a small percentage of coronary angiograms, with left main coronary artery (LMCA) aneurysms being the least common. We present a 63-year-old male patient with a history of chest pain and an abnormal nuclear stress test. Cardiac catheterization showed a large LMCA aneurysm with unusual quadfurcation left main (LM) anatomy, but otherwise showed no evidence of obstructive coronary artery disease. The patient remained clinically stable, and a repeat cardiac catheterization 2 years later showed unchanged coronary anatomy. Further medical management with close observation was elected. This case illustrates that in select cases, large LMCA aneurysms can be successfully managed medically without surgical or percutaneous interventions. To our knowledge, this is the first report of LMCA aneurysm with quadfurcation anatomy. In addition to the case description, a review of the literature is provided.

Prevalence, Predictors, and Impact of Coronary Artery Ectasia in Patients With Atherosclerotic Heart Disease

The clinical relevance of coronary artery ectasia (CAE) is poorly understood. We investigated the prevalence, potential predictors, and prognostic significance of CAE in patients with atherosclerotic coronary artery disease. Consecutive patients undergoing percutaneous coronary intervention (PCI) from January 2016 to December 2018 were included and followed up for 1 year. CAE was diagnosed as an abnormal dilation >1.5-fold the diameter of adjacent normal segments on angiography. A total of 590 patients with CAE were identified from 36 790 patients undergoing PCI (overall rate of CAE: 1.6%). In multivariate analysis, variables including body mass index >30 kg/m2 (risk ratio, RR: 2.413, P = .018), ever-smoking (RR: 1.669, P < .001), hypertension (RR: 1.221, P = .025), acute myocardial infarction at admission (RR: 1.343, P = .004), no diabetes (RR: .810, P = .023), previous myocardial infarction (RR: 1.545, P < .001), no left main disease (RR: .632, P = .008) and multiple-vessel disease (RR: 1.326, P = .001), increased C-reactive protein (RR: 1.006, P = .012) were predictors of CAE. The incidence of adverse cardiovascular outcomes did not differ significantly between patients with or without CAE (P = .203). CAE is not uncommon among patients undergoing PCI in this cohort study. The presence of CAE vs its absence had no significant impact on 1-year clinical outcomes after PCI.

A Case of Giant Left Circumflex Coronary Fistula Aneurysm with Unidentified Fistula

A coronary aneurysm is a rare type of cardiovascular disease. We report a case of a 53-year-old male patient who presented to our hospital with a giant left circumflex coronary fistula aneurysm (LCCA) (75 mm × 70 mm). Since coronary angiography and coronary computed tomography angiography failed to detect the fistula of the coronary aneurysm, interventional occlusion surgery could not be performed. We discovered the fistula in the right atrium by anterograde perfusion with blood-containing myocardial protective fluid after switching to intraoperative exploration during cardiac surgery. The coronary aneurysm's fistula and inlet were then sutured, and the aneurysm was resected. The patient recovered successfully after the operation. This case was instructive in managing LCCA, especially with an unidentified fistula.

[Imaging of coronary aneurysms in adults' coronary aneurysms]

Coronary aneurysms are rare and of various etiologies in adults. Natural history, modalities of management and clinical monitoring remain poorly known due to the lack of large studies and homogeneous diagnostic and follow-up criteria in the published data. Coronary angiography is, so far, the most common diagnostic tool but can overlook some partially thrombosed aneurysmal. Intracoronary imaging, particularly intravascular ultrasound, can differentiate aneurysms from pseudoaneurysms considered by some to be at greater risk of events, requiring a curative treatment. Intracoronary imaging can also help with etiological assessment and percutaneous treatment. With its growing use in the search for coronary atheromatous disease, coronary CT angiography has become a major diagnostic tool for coronary aneurysms. In addition, that it can incidentally detect coronary aneurysms, coronary CT angiography is particularly useful for giant aneurysms poorly visualized on coronary angiography or less well evaluated by intracoronary imaging. It specifies their relationship with adjacent anatomical structures. It is also a non-invasive modality of monitoring. These three imaging tools are currently the most relevant in current practice pending large studies evaluating the natural history of coronary aneurysms, with the identification of possible risk factors that could modify the management.

Two presentations of acute coronary syndrome with progression of giant right coronary artery aneurysm; a case report

Background

Giant coronary aneurysms are a rare finding on coronary angiography. Given its very low prevalence, little is known about optimal management of this coronary pathology.

Case summary

In this case report, we review the two presentations of a patient with acute coronary syndrome during a 6-year period. With regard to the second presentation, we review the investigations that demonstrate the progression of a coronary aneurysm in the right coronary artery as well as the Heart Team evaluations that resulted in surgical treatment of the coronary aneurysm.

Discussion

Following perspectives on prevalence and risk factors, we emphasize upon the available data with regard to interventional options in coronary aneurysms and describe the considerations with regard to interventional treatment in patients with giant coronary aneurysms. Finally, we discuss the available literature with regard to antithrombotic regimens in patients with coronary aneurysms.

Coronary Arteries Aneurysms: A Case-Based Literature Review

Coronary artery aneurysm (CAA) is an abnormal dilatation of a coronary artery segment; those coronary artery aneurysms that are very large in size are defined as giant. However, a standardized dimension cut-off to define giant CAAs is still missing. The reported prevalence of coronary aneurysms in the population who underwent coronary angiography ranges from 0.3% to 5%, and often CAAs are found in patient with aneurysms in other sites, such as the ascending or abdominal aorta. In half of the cases an atherosclerotic etiology could be recognized; often, CAA is found in the context of acute coronary syndrome. Seldomly, CAA is found at the autopsy of patients who died due to sudden cardiac death. Currently, very few data exist about CAA management and their prognostic relevance; moreover, CAA treatment is still not clearly codified, but rather case-based. Indeed, currently there are no published dedicated studies exploring the best medical therapy, i.e., with antiplatelets or anticoagulant agents rather than an interventional approach such as an endovascular or surgical technique. In this review, through two clinical cases, the current evidence regarding diagnostic tools and treatment options of CAAs will be described.

Etiology, clinical presentation, and management of left main coronary artery aneurysms

BACKGROUND AND AIM OF THE STUDY

The widespread use of noninvasive/invasive coronary imaging increased the probability of recognition of coronary aneurysms. Left main coronary aneurysms (LMCA), though rare, are potentially life-threatening but in the absence of controlled studies, guidelines do not provide any specific recommendation for their management. We, therefore, aimed to investigate the epidemiology, clinical presentation, therapeutic strategies, and prognostic implication of LMCA.

METHODS

A systematic review of the literature was performed to retrieve all the reported cases of LMCA as of December 2021, which were summarized and classified according to their etiology, clinical presentation, and therapeutic management.

RESULTS

Out of 1997 works retrieved, 180 studies were analyzed, describing 209 LMCA cases (aged 51 ± 19 years, 68% males). Atherosclerosis was the most common etiology (40%), followed by inflammatory (12%), congenital (9%), or degenerative (6%) conditions. Stable angina (43%) and acute coronary syndromes (32%) were more often the first clinical manifestations, while 29 (14%) LMCA were incidental findings. Most cases were treated surgically (53%), while percutaneous intervention was rarely adopted (7%). Data about antithrombotic therapies were scarce and heterogeneous. Finally, when longitudinal data were reported (n = 81), LMCA resulted associated with a severe prognosis, with a 15% mortality over an 8-month median follow-up.

CONCLUSIONS

LMCA are most frequently, but not exclusively, caused by advanced atherosclerosis. Irrespective of their etiology and clinical presentation, LMCA may be associated with high short-term mortality. In absence of controlled studies, a careful evaluation of each case is warranted to optimize therapeutic strategies.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

Coronary artery ectasia (CAE) is defined as a diffuse or focal dilation of an epicardial coronary artery, which diameter exceeds by at least 1. 5 times the normal adjacent segment. The term ectasia refers to a diffuse dilation, involving more than 50% of the length of the vessel, while the term aneurysm defines a focal vessel dilation. CAE is a relatively uncommon angiographic finding and its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography. Although its pathophysiology is still unclear, atherosclerosis seems to be the underlying mechanism in most cases. The prognostic role of CAE is also controversial, but previous studies reported a high risk of cardiovascular events and mortality in these patients after percutaneous coronary intervention. Despite the availability of different options for the interventional management of patients with CAE, including covered stent implantation and stent-assisted coil embolization, there is no one standard approach, as therapy is tailored to the individual patient. The abnormal coronary dilation, often associated with high thrombus burden in the setting of acute coronary syndromes, makes the interventional treatment of CAE patients challenging and often complicated by distal thrombus embolization and stent malapposition. Moreover, the optimal antithrombotic therapy is debated and includes dual antiplatelet therapy, anticoagulation, or a combination of them. In this review we aimed to provide an overview of the pathophysiology, classification, clinical presentation, natural history, and management of patients with CAE, with a focus on the challenges for both clinical and interventional cardiologists in daily clinical practice.

High frequency of coronary artery ectasia in obstructive sleep apnea

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) have a greater risk of developing coronary artery disease. However, the frequency of specific coronary artery vascular phenotypes, such as coronary artery ectasia (CAE), which has a frequency of 5% in the general population, has not been studied in patients with OSA. This study aimed to estimate CAE frequency in patients with OSA who underwent coronary angiography.

METHODS

A retrospective cross-sectional study was performed. The results of each polysomnography were reviewed, classifying OSA severity according to the apnea-hypopnea index. Each coronary angiography was reviewed. CAE was defined and classified according to the scales described in the literature. Two groups of patients were classified and compared (OSA/CAE group vs OSA/non-CAE group).

RESULTS

We identified the frequency of CAE in 185 patients with OSA who underwent coronary angiography. The frequency of CAE was 18.4% in these patients. ST-elevation myocardial infarction as the indication for coronary angiography was significantly greater in the OSA/CAE group than the OSA/non-CAE group (26.5% vs 9.9%; P = .02); 62% of the patients having severe OSA (apnea-hypopnea index ≥ 30 events/h). These patients in the OSA/CAE group had a significantly higher median apnea-hypopnea index than in the OSA/non-CAE group (72.5 events/h vs 53.5 events/h, respectively; P = .039). The CAE severity was not directly related to the OSA severity.

CONCLUSIONS

The frequency of CAE in patients with OSA is higher than that reported for the general population. The severity of OSA is related to the presence of CAE but not to its severity.

CITATION

del Portillo JH, Hernandez BM, Bazurto MA, Echeverri D, Cabrales J. High frequency of coronary artery ectasia in obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):433-438.

Arrhythmia Caused by a Giant Coronary Artery Aneurysm

Giant coronary artery aneurysms (GCAA) are rare cardiovascular malformations that necessitate a multimodal, interdisciplinary diagnostic and individualized interventional approach. We report the case of a young, healthy patient with an idiopathic GCAA with pseudoaneurysmatic protrusion into the right atrium, causing syncope, cardiac decompensation and arrhythmia that subsided post-operatively.

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry

Introduction

Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD.

Methods

Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding.

Results

Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015).

Conclusions

These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Sino-tubular junction to sinuses of Valsalva ratio: An echocardiographic parameter to predict coronary artery ectasia in patients with aortic enlargement

BACKGROUND

Coronary artery ectasia (CAE) is associated with ascending aortic (AA) ectasia. The purpose of this study is to evaluate the diagnostic performance of different echocardiographic parameters (EP) in predicting the presence of CAE.

METHODS

Four hundred-eighteen patients with AA ectasia candidate to coronary angiography were identified and divided in two groups in respect of the presence of CAE. Receiver-operating characteristic curves areas (AUC) were used to assess the discrimination power of the following EP: aortic annulus diameter, sinuses of Valsalva (SV) diameter, sino-tubular junction (STJ) diameter, AA diameter, STJ to SV ratio (STJ-to-SV) and STJ to AA ratio (STJ-to-AA). All these parameters were indexed by body surface area. The relationship between the best EP and the presence of CAE was investigated by means of multivariable logistic regression.

RESULTS

The rate of CAE in the study population was 32%. On univariable logistic regression, aortic annulus, STJ, STJ-to-SV and STJ-to-AA were associated with the presence of CAE after Bonferroni correction. STJ-to-SV emerged as the parameter with the best discrimination power (AUC = 0.81) compared to STJ (AUC = 0.69), STJ-to-AA (AUC = 0.68), aortic annulus (AUC = 0.59), AA (AUC = 0.56) and SV (AUC = 0.55); (p for comparison <0.01). An 89.6% value for STJ-to-SV ratio emerged as the best cut-off to diagnose CAE with a sensitivity = 75%, specificity = 82%, positive predictive value = 66% and negative predictive value = 88%. On multivariable analysis, STJ-to-SV was still associated with the presence of CAE (OR = 1.15;95%CI:1.11-1.19;p < 0.01).

CONCLUSION

In patients with dilated aorta, STJ-to-SV sampled by transthoracic echocardiography shows a good diagnostic performance in predicting the presence of CAE.

Usefulness of oral anticoagulation in patients with coronary aneurysms: Insights from the CAAR registry

OBJECTIVES

To assess the Usefulness of oral anticoagulation therapy (OAT) in patients with coronary artery aneurysm (CAA).

BACKGROUND

Data on the most adequate antithrombotic CAA management is lacking.

METHODS

Patients included in CAAR (Coronary Artery Aneurysm Registry, Clinical Trials.gov: NCT02563626) were selected. Patients were divided in OAT and non-OAT groups, according to anticoagulation status at discharge and 2:1 propensity score matching with replacement was performed. The primary endpoint of the analysis was a composite and mutual exclusive endpoint of myocardial infarction, unstable angina (UA), and aneurysm thrombosis (coronary ischemic endpoint). Net adverse clinical events, major adverse cardiovascular events, their single components, cardiovascular death, re-hospitalizations for heart failure, stroke, aneurysm thrombosis, and bleeding were the secondary ones.

RESULTS

One thousand three hundred thirty-one patients were discharged without OAT and 211 with OAT. In the propensity-matched sample (390 patients in the non-OAT group, 195 patients in the OAT group), after 3 years of median follow-up (interquartile range 1-6 years), the rate of the primary endpoint (coronary ischemic endpoint) was significantly less in the OAT group as compared to non-OAT group (8.7 vs. 17.2%, respectively; p = .01), driven by a significant reduction in UA (4.6 vs. 10%, p < .01) and aneurysm thrombosis (0 vs. 3.1%, p = .03), along with a non-significant reduction in MI (4.1 vs. 7.7%, p = .13). A non-significant increase in bleedings, mainly BARC type 1 (55%), was found in the OAT-group (10.3% in the non-OAT vs. 6.2% in the OAT group, p = .08).

CONCLUSION

OAT decreases the composite endpoint of UA, myocardial infarction, and aneurysm thrombosis in patients with CAA, despite a non-significant higher risk of bleeding.

Giant Coronary Aneurysm Causing Ostial Occlusion of Coronary Artery by Mass Effect: A Case Report

Coronary atherosclerosis can rarely lead to complications like giant coronary aneurysm (GCA), and acute myocardial infarction (AMI) due to thrombosis in the GCA is even rarer. Multimodality imaging is preferred over relying solely on selective coronary angiogram in such cases due to the limitations of invasive coronary angiogram in visualizing thrombosed aneurysms. We report a rare case of a patient with ST-elevation myocardial infarction caused by ostial occlusion of a right coronary artery (RCA) due to mass effect created by thrombosis in a GCA, thereby highlighting a mechanism of AMI that has not been previously described in GCA. Multimodality imaging led to the correct diagnosis and detection of the underlying mechanism, which had been completely missed by invasive coronary angiography (ICA). We also discuss the utility of multimodality imaging in such cases.

Outcomes of patients who undergo elective covered stent treatment for coronary artery aneurysms

BACKGROUND

Coronary artery aneurysms (CAA) are reported in up to 5% of patients undergoing coronary angiography. Treatment of CAAs with covered stents has been reported in several case reports, however there is limited evidence available on the effectiveness and safety of this interventional practice.

PURPOSE

To evaluate the current practice and outcomes of elective treatment of coronary artery aneurysms with covered stents.

METHODS

We conducted a systematic review of published case reports and case series of patients presenting with CAA that have been treated with covered stents in a non-emergency setting.

RESULTS

A total of 63 case reports and 3 case series were included in the final analysis comprising data from 81 patients. The treated CAA was situated in a native coronary artery in 92.6%, and in a saphenous vein graft in 7.4%. Procedural success was achieved in 95.1%. The types of stents used were mainly polytetrafluoroethylene (75.3%) and Papyrus (11.1%). In 11.0% of cases additional abluminal drug eluting stents (DES) and in 6.8% additional adluminal DES were implanted. After a mean follow up of 13.4 months overall major adverse cardiovascular events (MACE), mortality, myocardial infarction, stroke, stent thrombosis and target lesion revascularization were reported in 26.2, 0.0, 7.6, 0.0, 4.6 and 18.5% of cases, respectively.

CONCLUSIONS

The use of covered stents for elective treatment of CAA appears to be effective and reasonably safe. Nevertheless, it is associated with higher MACE rate, driven mainly by higher target lesion revascularization. Further studies, particularly in form of randomized trials and controlled registries are warranted to identify patients who might profit the most from this procedure.

Giant Aneurysm of the Right Coronary Artery: Multimodality Imaging and Interventional Management

A large (40-mm) circular structure in the right atrioventricular groove was detected by transthoracic echocardiography and was diagnosed as a giant aneurysm of the right coronary artery. Through invasive mapping by a guide extension catheter, the aneurysm could be excluded by implantation of 3 overlapping stent grafts. (Level of Difficulty: Beginner.).

Acute coronary syndrome in a young woman with a giant coronary aneurysm and mitral valve prolapse: a case report and literature review

Acute coronary syndrome in the young population is infrequently seen and has a different etiology from that in the elderly population. Giant coronary artery aneurysms are rare and usually asymptomatic, but they can cause acute clinical symptoms such as chest pain or chest tightness. We herein describe a young woman with a history of mitral valve prolapse who developed sudden-onset chest pain. She had mild elevations of her creatine kinase and cardiac troponin levels; however, no ST segment alteration was found on an electrocardiogram, and no abnormal regional wall movement was noted on echocardiography. Cardiac magnetic resonance imaging with late gadolinium enhancement revealed a "mass" at the right coronary artery and linear subendocardial enhancement at the posterior wall. Coronary angiography later confirmed a giant coronary aneurysm with a substantial thrombus. The combined presence of the coronary artery aneurysm and mitral valve prolapse in this patient was likely a sequela of Kawasaki disease.

Surgical exclusion of an idiopathic saccular aneurysm in the left main trunk of the coronary artery

Purpose

A coronary artery aneurysm (CAA) can result in critical cardiac events such as thromboembolic complications or rupture. A saccular CAA located in the left main trunk (LMT) is the most critical form of this pathology and its surgical repair is challenging. We conducted this single-center study to review the surgical outcomes of patients with a saccular CAA in the LMT.

Methods

Between May, 2012 and June, 2020, five patients with a saccular CAA in the LMT underwent surgery at our center. The median age at operation was 66.5 (59.7–69) years and the median diameter of the CAA was 13.0 mm (IQR 11–14 mm).

Results

The CAA was fully excluded by patch closure of the LMT orifice and direct closure of the distal LMT, supplemented by coronary artery bypass grafting with the exclusive use of arterial conduits. There was no in-hospital mortality, although one patient suffered graft spasm-related myocardial infarction with complete recovery. Post-operative angiography showed a fully excluded LMT in all patients. There was no mortality or adverse cardiac events during follow-up.

Conclusions

Our surgical policy for CAA in the LMT is feasible and safe; however, coronary blood flow is dependent on reliable bypasses.

Coronary artery aneurysms: outcomes following medical, percutaneous interventional and surgical management

BACKGROUND

Coronary artery aneurysms (CAAs) are increasingly diagnosed on coronary angiography; however, controversies persist regarding their optimal management. In the present study, we analysed the long-term outcomes of patients with CAAs following three different management strategies.

METHODS

We performed a retrospective review of patient records with documented CAA diagnosis between 2000 and 2005. Patients were divided into three groups: medical management versus percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). We analysed the rate of major cardiovascular and cerebrovascular events (MACCEs) over a period of 10 years.

RESULTS

We identified 458 patients with CAAs (mean age 78±10.5 years, 74.5% men) who received medical therapy (N=230) or underwent PCI (N=52) or CABG (N=176). The incidence of CAAs was 0.7% of the total catheterisation reports. The left anterior descending was the most common coronary artery involved (38%). The median follow-up time was 62 months. The total number of MACCE during follow-up was 155 (33.8%); 91 (39.6%) in the medical management group vs 46 (26.1%) in the CABG group vs 18 (34.6%) in the PCI group (p=0.02). Kaplan-Meier survival analysis showed that CABG was associated with better MACCE-free survival (p log-rank=0.03) than medical management. These results were confirmed on univariate Cox regression, but not multivariate regression (OR 0.773 (0.526 to 1.136); p=0.19). Both Kaplan-Meier survival and regression analyses showed that dual antiplatelet therapy (DAPT) and anticoagulation were not associated with significant improvement in MACCE rates.

CONCLUSION

Our analysis showed similar long-term MACCE risks in patients with CAA undergoing medical, percutaneous and surgical management. Further, DAPT and anticoagulation were not associated with significant benefits in terms of MACCE rates. These results should be interpreted with caution considering the small size and potential for selection bias and should be confirmed in large, randomised trials.

Safety and efficacy of rotational atherectomy in heavily calcified lesions involving coronary aneurysms

Percutaneous transluminal rotational atherectomy (PTRA) is one of the most used techniques to facilitate percutaneous coronary intervention in heavily calcified coronary lesion (CCL). Coronary aneurysms (CAs) are detected in 1.2-4.9% of coronary angiogram. The presence of CA and CCL is infrequent but not rare, where the use of PTRA may be mandatory despite the high risk. After a complex procedure of PTRA in a CCL with CA we decided to investigate about this particular condition. We identified a total of six patients among 174 consecutive percutaneous coronary intervention (3.4%). All the procedures showed good stent expansion in the absence of major complications, such as no-reflow or coronary perforation. Cardiovascular death, rehospitalization for myocardial infarction and target lesion failure were not reported at follow-up (252 ± 152 days).

Use and outcomes of the PK Papyrus covered stent in France: SOS PK Papyrus Registry

OBJECTIVES

To evaluate the rate of procedural success and long-term outcomes of the PK Papyrus (PKP) covered stent (CS).

BACKGROUND

CS are essential in the treatment of coronary artery perforation (CAP). They have also been used to treat coronary artery aneurysms. Limited evidence is available on clinical outcomes with the PKP.

METHODS

This was a multicenter, observational, retrospective, and prospective study. Consecutive patients undergoing intentional PKP implantation in 22 centers in France were included. The primary endpoint was the rate of procedural success. Secondary endpoints included rates of death, myocardial infarction (MI), target lesion revascularization (TLR), in-stent restenosis (ISR), and stent thrombosis (ST).

RESULTS

Data from 130 patients were analyzed (mean age 72.5 ± 10.5 years; 71% men). The main indication for PKP was CAP, in 84 patients (65%). Delivery success was achieved in 95% and procedural success in 91%. During the in-hospital stay, 15 patients died (12%) and 7 (5%) presented with ST. Data from 127 patients were available at 19.2 ± 12.8 month follow-up. Thirty-three patients died (26%), 15 (12%) had an MI and 21 (17%) presented with TLR. TLR was due to ISR in 12 patients (9%), 10 had definite ST (8%) and 1 patient for stent under-expansion.

CONCLUSIONS

The principal indication for PKP was CAP. PKP had high rates of delivery and procedural success. At long-term follow-up, there was a high rate of TLR, mainly due to ISR and ST. These results are consistent with previously reported data in these clinical settings.

Correlation between aortic root dimension and coronary ectasia

BACKGROUND

Aortic aneurysms are associated with coronary artery ectasia (CAE). However, the relation between the extent of CAE and the severity of aortic dilatation is not understood. This study was undertaken to investigate the relationship between angiographic extension of CAE and aortic dimension.

PATIENTS AND METHODS

We retrospectively include 135 patients with angiographic diagnosis of CAE defined as dilatation of coronary segment more than 1.5 times than an adjacent healthy one. Study population was divided in four groups according to the maximum diameter of ascending aorta beyond sinus of Valsalva obtained in the parasternal long-axis view (group 1: <40 mm; group 2: 40-45 mm; group 3: 45-55 mm; group 4: >55 mm or previous surgery because of aortic aneurysm/dissection). The relationship between aortic dimension and the extension of CAE was investigated by means of multivariable linear regression, including variables selected at univariable analysis (P < 0.1). The total estimated ectatic area (EEA total) was used as dependent variable.

RESULTS

Baseline characteristics of study groups were well balanced. Patients in group 4 were more likely to have both higher neutrophil count and neutrophil to lymphocyte ratio. On univariable analysis ascending aorta diameter [Coef. = 0.075; 95% confidence interval (CI) 0.052-0.103, P < 0.01] and c-reactive protein (CRP) values [Coef. = 0.033, 95% CI 0.003-0.174, P = 0.04] showed a linear association with total EEA. After adjustment for CRP values only the ascending aorta diameter was still associated with the extent of CAE (95% CI 0.025-0.063, P < 0.01).

CONCLUSION

In patients with diagnosis of CAE, a strong linear association between aortic dimension and coronary ectasia extent exists.

A rare case of Kawasaki disease with giant coronary artery aneurysm

Kawasaki disease (KD) is an acute, self-limiting vasculitis that occurs in children of all ages. This was first described by Kawasaki in 1967. Spontaneous regression is observed; however, 25% of patients develop coronary artery aneurysm (CAA). These may result in ischaemic heart disease causing myocardial infarction, rupture leading to pericardial tamponade and distal embolization which culminate in sudden cardiac death. Diagnosis of KD relies on clinical suspicion with no gold standard diagnostic test. A case of KD with giant CAA in a 14-year-old female is described with emphasis on challenges pre- and peri-operatively. The review provided post description of the case emphasizes on pathophysiology with clinical course of CAA in association with KD and justification of our approach with an insight into newer treatment modalities.

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.

Giant Right Coronary Artery Aneurysms

Described herein are 2 adults with right coronary artery aneurysms measuring ≥4.0 cm in maximal diameter. Each aneurysm contained huge intra-aneurysm thrombus and each coronary artery contained atherosclerotic plaques diffusely. Each aneurysm was resected without complication and each patient has resumed preoperative level of activities without limitations.

Extensive coil embolization of a giant coronary artery aneurysm in an octogenarian: a case report

Background

Coronary artery aneurysms (CAA) are often diagnosed incidentally on coronary angiography or imaging modalities done for other reasons. ‘Giant’ CAA by definition exceeds 20 mm in diameter or four times the diameter of normal coronary artery. The management of patients with CAAs is challenging due to poorly understood mechanism, variable presentation, and lack of clear-cut societal recommendations. Though conservative management is preferred in asymptomatic patients, massive size or interval growth may make intervention necessary.

Case summary

We describe a case of successful coil embolization of a giant coronary aneurysm in an elderly 84-year-old male. Patient, who presented for a follow-up computed tomography angiography to evaluate a previously repaired abdominal aortic aneurysm 2 years back, was found to have interval growth of right coronary artery aneurysm from 4 cm in diameter to 7 × 8 cm in its greatest dimensions. The rationale for treatment was to prevent sudden death from continued growth and eventual rupture of aneurysm in addition to potential risk of thromboembolism and compression of adjacent structures.

Discussion

This case demonstrates the safe and successful use of extensive coil embolization technique to treat a ‘giant’ CAA in an elderly patient when surgical risks were prohibitive.

A Rare Complication of Chronic Active Epstein-Barr Virus Infection

A 42-year-old man with a 6-month-long fever was found to have chronic active Epstein-Barr virus infection complicated by aneurysmal coronary arteries with other arteries. In adult patients with this infection, coronary aneurysms are rare but are a poor prognostic factor. (Level of Difficulty: Intermediate.)