Coronary artery aneurysms after drug-eluting stent implantation

A Giant Coronary Aneurysm Formation After RCA CTO Recanalization

Formation of a coronary artery aneurysm (CAA), especially a giant CAA, after percutaneous coronary intervention for chronic total occlusion (CTO) is a rare complication. Therapeutic approaches include surgical procedure, covered stent, and medical treatment. Here, we report a 47-year-old man readmitted due to chest distress who had undergone right coronary artery CTO recanalization 6 months earlier. Diagnostic coronary artery angiography revealed a giant aneurysm at the stented middle segment of the right coronary artery; it was >20 mm in diameter. This is the first report on a secondary giant CAA after CTO recanalization that was subsequently excluded with deployment of a covered stent.

Diagnosis and Management of Post-PCI Left Circumflex Coronary Artery Pseudoaneurysm

BACKGROUND

Coronary artery pseudoaneurysms (PSAs) are a rare but potentially life-threatening complication after percutaneous coronary intervention (PCI), typically manifesting between 1 week and 4 years after the procedure. Prompt diagnosis is crucial, particularly in high-risk PSAs, which incur potential for rupture.

CASE SUMMARY

The authors report the case of a 77-year-old man in whom a large PSA developed in the left circumflex artery within 30 days of PCI, which was complicated by coronary perforation. During the original procedure, the perforation was sealed by a covered stent; however, anticoagulation was resumed because of atrial fibrillation 2 weeks later. The patient subsequently presented again with chest discomfort, and computed tomographic angiography showed a large PSA at the edge of the stent. Percutaneous closure using a second covered stent achieved complete PSA isolation.

DISCUSSION

This case aims to highlight the importance of precise stent placement, vessel wall apposition, and vigilant follow-up, particularly in patients taking intensive antithrombotic therapy.

OCT-Guided covered stent implantation for acquired coronary aneurysm after bioresorbable vascular scaffold: case report

Coronary artery aneurysm (CAA) formation following bioresorbable vascular scaffold (BVS) implantation is a rare but serious complication with no clear treatment guidelines. We report the case of a 56-year-old man with coronary artery disease (CAD) and a chronic total occlusion (CTO) in the left anterior descending artery (LAD) underwent full revascularization with BVS in 2016. Seven years later, he experienced recurrent angina, and angiography revealed 80% stenosis in the proximal LAD and a large coronary aneurysm in the middle LAD. Optical coherence tomography (OCT) confirmed a 5.88 mm aneurysm, which was treated with a PK Papyrus covered stent, while the proximal LAD stenosis was addressed with a Resolute Onyx drug-eluting stent (DES). After six months of standard dual antiplatelet therapy (DAPT) followed by three months of single antiplatelet therapy (SAPT), the patient developed in-stent restenosis (ISR) in the covered stent. This was successfully treated with high-pressure balloon angioplasty and a drug-eluting balloon (DEB). At the nine-month follow-up, the patient remained symptom-free. This case highlights the utility of OCT in evaluating CAAs and guiding covered stent deployment, while prolonged DAPT may help reduce the risk of very late stent thrombosis and future ischemic events, though further studies are needed.

Managing a Right Coronary Artery Perforation, Pseudoaneurysm, and the Fight for Patency

Managing coronary perforation under anticoagulation presents a clinical dilemma. This case explores the challenge of preserving vessel patency while addressing perforation. A 76-year-old woman presented with acute chest pain and inferior ST-segment depression. Angiography revealed a small-caliber right coronary artery with faint collateral flow. During percutaneous coronary intervention, an Ellis type III perforation occurred, managed with balloon tamponade and pericardiocentesis. Using the ping-pong technique, flow was restored without reversing anticoagulation. A pseudoaneurysm developed at the perforation site, which was treated successfully with coil embolization. This case highlights the balance required between bleeding risk and ischemic burden in acute coronary syndrome. It underscores the importance of advanced percutaneous coronary intervention techniques like the ping-pong strategy for effective intervention and management of complications such as pseudoaneurysms.

MINOCA as the result of coronary artery aneurysm thrombosis

Myocardial infarction (MI) can be caused by many factors. In addition to the typical obstruction or stenosis of the coronary arteries, there is heterogenic MI with non-obstructive coronary arteries (MINOCA). A rare cause of MINOCA is the thrombosis of a coronary artery aneurysm (CAA). This current case report describes a male patient with CAA thrombosis as the cause of MINOCA following surgery for a mucoepidermoid carcinoma. The patient underwent angiography that identified three CAAs that were located as follows: (i) in the proximal part of the left anterior descending artery (5.55 mm); (ii) in the distal part of the circumflex artery (8.05 mm); and (iii) in the distal part of the right coronary artery (6.61 mm). Thrombotic masses were identified within all three structures. The patient received balloon angioplasties without stent implanting and recovered well. The patient was also notable for the presence of two brain artery aneurysms that were the cause of the previous strokes that he had experienced. This case report also reviews the literature in order to: (i) summarize the aetiological factors and clinical manifestations of CAA; (ii) discuss the diagnostic methods for CAA; (iii) describe the medical and surgical management of CAA; and (iv) assess the prognosis of this rare clinical event.

Long-Term Prognosis of Coronary Aneurysms: Insights of CAAR, an International Registry

BACKGROUND

Limited data are available to guide the management of coronary artery aneurysms (CAAs).

OBJECTIVES

The authors sought to define the clinical characteristics, identify variables that predict outcomes, and provide long-term data on CAAs.

METHODS

We describe outcomes from 1,729 consecutive patients with CAAs included in an ambispective international registry (CAAR [Coronary Artery Aneurysm Registry]; NCT02563626) involving 33 hospitals across 9 countries in America and Europe.

RESULTS

Patients were predominantly male (78.6%; 1,359/1,729) with a mean age of 66 years. Classic cardiovascular risk factors were common, as well as coronary artery disease (85.8%; 1,484/1,729), peripheral vascular disease (10.9%; 188/1,729), and chronic kidney disease (8.0%; 138/1,729). The median number of aneurysms per patient was 1.0 (Q1-Q3: 1.0-1.0), with the most affected territory being the left anterior descending artery (49.6%; 857/1,729). The majority underwent any revascularization procedure (68.5%; 1,184/1,729), mainly percutaneous coronary intervention (50.7%; 877/1,729), and were discharged on dual antiplatelet therapy (65.6%; 1,134/1,729). After a median follow-up of 44.8 months (Q1-Q3: 14.9-88.1), 379 died (21.9%), and 641 (37.1%) developed a major adverse cardiovascular event (MACE) (all-cause death, heart failure, unstable angina, and reinfarction). In a multivariable analysis, age (HR: 1.03; 95% CI: 1.02-1.04; P < 0.001), diabetes mellitus (HR: 1.47; 95% CI: 1.23-1.75; P < 0.001), renal insufficiency (HR: 1.53; 95% CI: 1.19-1.96; P = 0.010), peripheral vessel disease (HR: 1.43; 95% CI: 1.13-1.82; P = 0.003), reduced left ventricular ejection fraction (HR: 0.98; 95% CI: 0.98-0.99; P < 0.001), acute indication for the index coronary angiography (HR: 1.30; 95% CI: 1.08-1.55; P = 0.005), and the number of coronary vessels presenting severe stenosis (HR: 1.11; 95% CI: 1.02-1.20; P = 0.015) were independent predictors of MACEs. Remarkably, only 37 patients presented with local aneurysm complications during follow-up.

CONCLUSIONS

The long-term prognosis of CAAs is not favorable, with MACEs associated with the underlying risk factor profile for atherosclerotic heart disease.

Coronary Artery Anomalies: Diagnosis & Management

Coronary artery anomalies encompass a spectrum of congenital abnormalities affecting the origin, course, or termination of the major epicardial coronary arteries. Despite their rarity, coronary artery anomalies represent a significant burden on cardiovascular health due to their potential to disrupt myocardial blood flow and precipitate adverse cardiac events. While historically diagnosed postmortem, the widespread availability of imaging modalities has led to an increased recognition of coronary artery anomalies, particularly in adults. This review synthesizes current knowledge on the classification, mechanisms, and clinical implications of coronary anomalies, focusing on prevalent variants with significant clinical impact. We discuss strategies for medical and surgical management, as well as contemporary screening recommendations, acknowledging the evolving understanding of these anomalies. Given the breadth of possible variants and the limited data on some presentations, this review provides a framework to aid clinicians in the recognition and management of coronary anomalies, with a particular emphasis on their stratification by anatomical location. By consolidating existing knowledge and highlighting areas of uncertainty, this review aims to enhance clinical decision-making and improve outcomes for individuals with coronary anomalies.

Coronary Artery Aneurysms: A Clinical Case Report and Literature Review Supporting Therapeutic Choices

Coronary artery aneurysms (CAAs) are uncommon but significant cardiovascular abnormalities characterized by an abnormal increase in vascular diameter. CAAs are classified based on their shape as either saccular or fusiform, and their causes can range from atherosclerosis, Kawasaki disease, to congenital and iatrogenic factors. CAAs often present asymptomatically, but when symptoms occur, they can include angina, myocardial infarction, or even sudden cardiac death due to intravascular thrombosis involving the CAA. Diagnosis is typically confirmed through coronary angiography, though CT and other imaging techniques can provide additional details. The management of CAAs is variable depending on their size, location, and the presence of symptoms or complications. Treatment options include medical therapy, percutaneous coronary intervention (PCI), or surgical approaches. In this paper, we describe the case report of a 79-year-old male who presented with palpitations and was diagnosed with a right coronary artery aneurysm, and a review of the literature is delineated, underscoring the importance of individualized treatment strategies for CAAs.

Recurrence following percutaneous exclusion of giant coronary pseudoaneurysm: a case report

BACKGROUND

Emergence of coronary giant pseudoaneurysm (PSA) after stent implantation is potentially catastrophic and may end up with life threatening complications if not managed promptly. There is scarcity of data in existing literature with respect to guidelines on the management of coronary PSA following stent implantation. We report the recurrence of coronary PSA following initial percutaneous management of a giant coronary PSA using multiple stent grafts.

CASE PRESENTATION

A 38-year-old male who underwent primary angioplasty of the right coronary artery (RCA) about a month back, presented with dull aching precordial chest pain for the last 15 days. A repeat coronary angiography revealed giant coronary PSA in proximal to mid RCA. Considering the significantly large size of the coronary PSA with symptoms of impending rupture, the giant coronary PSA was successfully excluded by implanting three sequentially coronary stent grafts. However, after one and a half months, the patient again presented with a similar kind of dull aching chest pain. We found a recurrence of coronary PSA in a segment of the coronary artery distal to the portion excluded by stent grafts. This recurrent coronary PSA was once again successfully excluded by redeploying two more stent grafts with the help of a guide extension catheter.

CONCLUSIONS

In this case, vessel wall injury as a result of aggressive post dilatation using an oversized balloon during the index procedure was the contributor to the giant coronary PSA formation. It usually appears early after the index procedure (within 4 weeks). Though the usual strategy used to exclude coronary aneurysm is by using the minimal number of stent grafts (due to the inherent increased risk of restenosis/thrombosis in stent grafts) in post angioplasty traumatic aneurysm it is prudent to exclude the entire damaged artery by placing stent grafts to prevent recurrence in segments with even minimal dilatation on initial evaluation.

A case report of coronary artery aneurysms with restenosis and stent fractures developed 14 years after sirolimus eluting stents implantation successfully treated with drug-coated balloons

Background

Coronary aneurysms following drug-eluting stent implantation are rare but associated with adverse events.

Case summary

An 80-year-old male admitted to our hospital with resting chest discomfort. He had undergone percutaneous coronary interventions (PCIs) with first-generation sirolimus-eluting stent (SES) implantation to the right coronary artery (RCA) and left anterior descending artery (LAD) 14 years ago. Coronary angiography revealed coronary aneurysms and stent fractures in the RCA and LAD where SES was implanted. The aneurysm sizes of the RCA and LAD were 7 × 8 and 7 × 10 mm, respectively. Moreover, in-stent restenosis (ISR) with ischaemia were found in the LAD. The patient was at high risk for cardiac surgery and the coronary aneurysms were not suitable for percutaneous interventions. Therefore, we treated only ISR lesions using drug-coated balloons (DCBs) without intervention for coronary aneurysms. Intravascular ultrasound (IVUS) revealed that the first guide wire went outside the malapposed stents. After rewiring using a double-lumen microcatheter with another guide wire, IVUS confirmed the second guide wire passed entirely inside the stents. Then, the ISR lesions were dilated with high-pressure balloons and DCBs. The post-procedural course was uneventful and his symptoms were relieved.

Discussion

This case demonstrated coronary aneurysms with ISR and stent fractures 14 years after SES implantation. Depending on patient background and lesion morphology, DCB can be one of the treatment options. Intravascular imaging is useful to guide PCI in patients with coronary aneurysms.

Late acquired coronary aneurysm and restenosis after bioresorbable vascular scaffold implantation: a case report

Background

Although the technology of bioresorbable vascular scaffold (BVS) aroused the peak of interest a few years ago and currently remains available only as part of experimental research, patients who have had BVS implanted should be still carefully monitored to detect possible long-term complications.

Case summary

We present the case of a 47-year-old man who had received BVS implantation for ST-segment elevation myocardial infarction. Six years later, computed tomography coronary angiography (CTCA) demonstrated in-segment restenosis in between two newly formed coronary aneurysms at the site of the implanted BVS. The patient received successful optical coherence tomography-guided percutaneous intervention with a new metallic drug-eluting stent implantation.

Discussion

Our case demonstrates that coronary aneurysms can be well characterized with CTCA and are often incidentally discovered as they cause no symptoms. The incidence of coronary aneurysm at the site of a previously implanted BVS is not defined, and little is known about the pathophysiology and evolution of these lesions. Therefore, the decision to proceed with conservative management or intervention must be tailored to the clinical conditions of the patient, the anatomy, the rapidity of growth, and the possible thrombotic burden.

In-Hospital Outcomes and Conditions Associated With Coronary Artery Aneurysms in Chronic Coronary Syndrome

BACKGROUND

Coronary artery aneurysms (CAA) are infrequent findings among patients undergoing coronary angiography and may be associated with systemic diseases.

METHODS

We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the chronic coronary syndrome (CCS). We sought to determine the impact of CAA on in-hospital outcomes encompassing all-cause death, bleeding, cardiovascular complications, and stroke. Secondly, we examined the association of CAA with other relevant systemic conditions.

RESULTS

The presence of CAA was associated with a 3-fold increase in the odds of cardiovascular complications (OR 3.1, 95 % CI 2.9-3.8), however, it was associated with reduced odds of stroke (OR 0.7, 95 % CI 0.6-0.9). There was no significant impact on all-cause death and overall bleeding complications, although there appeared to be a reduction in the odds of gastrointestinal (GI) bleeding associated with CAA (OR 0.6, 95 % CI 0.4-0.8). Patients with CAA vs. those without CAA had a significantly greater prevalence of extracoronary arterial aneurysms (7.9 % vs. 1.4 %), systemic inflammatory disorders (6.5 % vs. 1.1 %), connective tissue disease (1.6 % vs. 0.6 %), coronary artery dissection (1.3 % vs. 0.1 %), bicuspid aortic valve (0.8 % vs. 0.2 %), and extracoronary arterial dissection (0.3 % vs. 0.1 %). In the multivariable regression, systemic inflammatory disorders, extracoronary aneurysms, coronary artery dissection, and connective tissue diseases were independent predictors of CAA.

CONCLUSIONS

CAA in patients with CCS is associated with greater odds of cardiovascular complications during hospitalization. These patients also had a substantially greater prevalence of extracardiac vascular and systemic abnormalities.

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 noninvasive 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.

Treatment of coronary pseudoaneurysm detected after percutaneous coronary intervention for chronic total occlusion: A case report

BACKGROUND

Coronary pseudoaneurysm (CPA) are associated with iatrogenic coronary artery dissection or perforation, which rarely reported formation early after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study reported a case of CPA that developed 4 weeks after PCI for CTO.

CASE REPORT

A 40-year-old man was admitted with unstable angina and diagnosed with CTO of the left anterior descending artery (LAD) and right coronary artery. The CTO of the LAD was successfully treated by PCI. However, reexamination by coronary arteriography and optical coherence tomography after 4 weeks confirmed a CPA at the stented middle segment of the LAD. The CPA was treated surgically by the implantation of a Polytetrafluoroethylene-coated stent. reexamination at the 5-month follow-up revealed a patent stent in the LAD and no CPA-like manifestations. Intravascular ultrasound showed no intimal hyperplasia or in-stent thrombogenesis.

CONCLUSION

CPA might develop within weeks after PCI for CTO. While it could be successfully treated by the implantation of a Polytetrafluoroethylene-coated stent.

Surgical management of drug-eluting stent associated coronary artery aneurysms: a case series

Drug-eluting stents (DES) have been introduced to counter the in-stent restenosis associated with bare metal stents. However, the mechanism of action of DES results in a counter-productive effect of coronary artery aneurysm (CAA) formation. Although CAA after the implantation of drug-eluting stents (DES) is a rare occurrence with an incidence rate of up to 0.5%, they are increasingly being detected due to the progressive rise in the usage of DES for the management of coronary artery disease (CAD). Due to the rarity of this condition, evidence and guidelines regarding the management strategies for this condition are still lacking. We present a series of 5 cases of CAA, post-DES implantation, who were all successfully managed with surgical intervention.

Giant coronary pseudoaneurysm associated with stent fracture treated successfully with coil embolization and a vascular plug

A 59-year-old man with acute cholangitis was referred to us because of a coronary artery aneurysm that was incidentally detected on contrast-enhanced computed tomography. Intravascular ultrasonography showed a loss of vascular layers and complete stent fracture, which was suggestive of a pseudoaneurysm. After some management protocols, such as observation, covered stent implantation, and surgical treatment, had failed, we treated the pseudoaneurysm successfully using coil embolization and a vascular plug. There were no complications during the perioperative period. We suggest that, if conventional management fails, treatment with coil embolization and a vascular plug should be considered.

Learning objective

A rare complication of percutaneous coronary intervention resulting from stent fracture is a coronary artery aneurysm. Here, we discuss the chronic complications of stent implantation and discuss the optimal management strategy for coronary pseudoaneurysms. Further, we discuss the strengths and weaknesses of each strategy.

"Floating" Stent in a Coronary Aneurysm Presenting as ST-Elevation Myocardial Infarction

Coronary artery aneurysm (CAA) presenting as an ST-elevation myocardial infarction (STEMI) represents a clinical challenge due to the technical difficulties in the percutaneous management of this specific situation. Appropriate treatment for CAA depends on the precise clinical situation and consists of medical management, surgical resection, or/and stent placement. The high rate of complications during percutaneous intervention (distal thrombus embolization, no-reflow phenomenon, stent malposition, or dissection) makes emergent surgery a frequent situation in these cases. We present the case of a 50-year-old man with a STEMI due to thrombotic occlusion of CAA. Specific angiographic techniques and intracoronary imaging help with the percutaneous management of acute thrombotic occlusions in CAA, providing a less invasive approach than emergent surgery.

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.

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.

Progression and interventional therapy of a coronary pseudoaneurysm: a case report

Background

Coronary pseudoaneurysms (PSAs) occur as a rare complication following drug-eluting stent implantation and have been reported to occur between 1 week and 4 years after implantation. Most of them remain in a stable state, but progression of PSAs increases the risk of rupture and haemorrhagic cardiac tamponade.

Case summary

Here, we present a case of a 55-year-old patient, who developed a PSA of the proximal left circumflex artery after stent implantation of the left main artery, left anterior descending artery, and left circumflex artery. Within <1 year, the patient was readmitted to different hospitals due to cardiac decompensation and myocardial infarction. Thereafter, coronary angiography and computed tomography scans were performed, and progression of the PSA could be documented. Interventional therapy was chosen due to the high surgical risk of the patient. Implantation of a covered stent from the left main artery into the left anterior descending artery was chosen to treat the PSA, thereby silencing the chronically occluded left circumflex artery, followed by dilatation with a non-compliant balloon. The patient has remained asymptomatic in a 6-month follow-up.

Discussion

Coronary PSA should be controlled with respect to progression, and appropriate therapy can be chosen for treatment.

[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.

A case report of pseudoaneurysm of coronary artery within a month of percutaneous coronary intervention

Background

Coronary artery pseudoaneurysms (PSAs) are uncommon and have poorly understood natural history. Unlike true aneurysms, PSAs do not have all the three layers of the vessel in the aneurysmal wall. The PSAs are most commonly seen after an overzealous percutaneous coronary intervention (PCI) which causes damage to the vessel wall. They usually develop slowly after PCI and PSAs within a month of a PCI are not so common. The PSA may be asymptomatic or present with recurrent angina.

Case summary

Here, we report a case of symptomatic PSA to right coronary artery (RCA). The patient had a myocardial infarction for which a PCI was performed to deploy a drug-eluting stent (DES) in the RCA. The patient had in-stent restenosis (ISR) within a week of PCI for which plain old balloon angioplasty (POBA) was performed. The patient continued to have unstable angina and within a month of POBA was diagnosed as a case of PSA by intravascular ultrasound. A covered stent was deployed which effectively sealed off the PSA and resumed normal blood flow to distal vessel. Patient has been doing well on medication [aspirin 75 mg once daily, atorvastatin 80 mg once daily, and P2Y12 platelet inhibitor (Ticagrelor) 90 mg twice daily].

Discussion

The PSAs usually take 6-9 months to develop. However, PSAs have been reported within 1-2 months of PCI. This case also shows that PSAs can occur within a month of PCI. It is possible that over-aggressive and/or high-pressure dilatation and/or deep engagement during POBA performed to open up the ISR could have damaged the struts of the DES and compressed it against the vascular wall. The resultant vascular wall injury could have been the cause of early PSA formation in this case. Hence, cardiologists should be vigilant enough to suspect PSA, especially in a patient presenting with angina. The case also shows that covered stents are a viable option to treat early presentations of PSA.

Case series of coronary artery aneurysms after Everolimus eluting stent implantation and comparison with Sirolimus eluting stents

Background

Coronary artery aneurysms after drug eluting stents are rare. We present a case series of type II coronary aneurysms after implantation of Everolimus eluting stents including patients developing giant aneurysms with a toxic course.

Case presentation

Over a span of 3.5 years at our center 2572 patients were implanted Everolimus eluting stents out of which 4 patients developed coronary type II aneurysms an incidence of 0.00156 whereas 5838 patients were implanted Sirolimus eluting 2nd generation stents out of which 2 patients developed similar aneurysms with an incidence of 0.00034. The slight increase in incidence in Everolimus stents does not reach statistical significance (p = 0.054) and is limited by single centre non randomized study. We also propose a hypothesis that the slight increase in the incidence maybe due to allergy to Methacrylate present in Everolimus eluting Xience stent’s primer which is absent in other Sirolimus eluting stents used at our center but that needs to be further investigated. We also found some patients who developed giant aneurysms including Left main aneurysms. In our series operative repair of these patients had better outcomes than covered stent deployment but larger trials maybe needed to confirm the same.

Conclusions

Coronary artery aneurysms after stent implantation are rare but occasionally giant aneurysms are formed with a toxic course. The incidence and morphology of aneurysms after Everolimus and Sirolimus eluting stent deployment do not differ much.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02503-1.

Double Whammy: Subacute Stent Thrombosis While Being Adherent to Dual Antiplatelet Therapy Including Ticagrelor, Followed by Multiple Coronary Artery Aneurysms in a COVID-19 Patient

Coronavirus disease 2019 (COVID-19), although predominantly a respiratory illness, can have important cardiovascular implications, which include the development of myocardial injury/myocarditis, acute coronary syndromes, arrhythmias, pericarditis, and the occurrence of arterial and venous thrombosis. We describe a rare case of a middle-aged COVID-19 patient who developed sub-acute stent thrombosis after implantation of second-generation drug-eluting stents (DES) despite being adherent to dual antiplatelet therapy including ticagrelor and who subsequently developed multiple coronary artery aneurysms within a few weeks of the DES implantation.

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.

The Impact of C-Peptide and Diabetes Mellitus on Coronary Ectasia and Effect of Coronary Ectasia and C-Peptide on Long-Term Outcomes: A Retrospective Cohort Study

BACKGROUND

Coronary artery ectasia (CAE) is an entity frequently associated with atherosclerotic coronary artery disease (CAD) in clinical practice. Although it has common risk factors with atherosclerotic CAD in its development, the pathophysiology of CAE is not fully known and it is not seen in every CAD suggesting that different determinants may play a pivotal role in the development of CAD. This study aimed to reveal the impact of C-peptide and diabetes mellitus (DM) on CAE and the effect of C-peptide and coronary ectasia on long-term outcomes in patients who underwent coronary angiography.

METHODS

A total of 6611 patients who underwent coronary angiography were followed up retrospectively, and their major adverse cardiovascular event (MACE) status of an average of sixty months was recorded. According to their angiographic features, the patients were divided into two groups those with and without CAE. MACE development was accepted as the primary endpoint.

RESULTS

A total of 552 patients had CAE and MACE developed in 573 patients. Patients with CAE and higher C-peptide levels (Q4 + Q3) showed higher rates of MACE as compared to those without CAE and lower C-peptide levels (Q1 + Q2) (20.8% vs 7.6%; 70.1% vs 29.1%; p < 0.001, for both of them). In multivariate regression analysis, high C-peptide levels were determined as an independent risk factor for CAE (OR 2.417; 95% CI 2.212-2.641; p < 0.001). The Kaplan-Meier cumulative survival curves showed that the risks for MACE increased as the C-peptide levels increased. The Cox regression analysis for 5-years MACE related to the plasma C-peptide levels and presence of CAE, C-peptide, and CAE were found to be independent predictors of MACE (HR = 1.255, 95% CI: 1.164-1.336, p < 0.001 and HR = 1.012, 95% CI: 1.002-1.023, p=0.026, respectively).

CONCLUSION

Our study revealed that a high C-peptide level is an independent risk factor for CAE and that CAE and C-peptide are independent predictors for the development of MACE.

Incidence of Restenosis Following Rapamycin or Paclitaxeleluting Stent in Coronary Stent Implantation

BACKGROUND & OBJECTIVES

Coronary artery disease (CAD) is chiefly characterized by atherosclerosis and plaque formation in coronary arteries. The aim of this study was to evaluate the correlation of coronary anatomy as a predictor of restenosis and stent thrombosis in coronary artery disease (CAD) patients 5 years after percutaneous coronary intervention (PCI).

METHODS

In this prospective study, 1070 patients with stent restenosis or stent thrombosis over past 5 years were enrolled. Coronary angiography was performed to evaluate coronary restenosis and stent thrombosis 5 years after PCI. Stent restenosis was defined as >50% angiographic in-stent lumen reduction. Stent thrombosis was defined as sudden complete occlusion of stent presenting with acute myocardial infarction in that territory. Demographic data, clinical features and anatomic factors were prospectively reviewed. Baseline, procedural, and post-procedural characteristics of patients were recorded for analysis.

RESULTS

Among demographic characteristics, cardiovascular risk factors (hypertension and diabetes mellitus) and anatomic factors were predictive risk factors for restenosis/thrombosis, p=0.001. The most common site for stent restenosis was proximal to the mid part of the LAD artery, followed by RCA and LCX. A greater diameter of LCX, a greater angle of LM-LAD than LM-LCX and left dominancy increase the incidence of LAD stent restenosis/thrombosis. In this study, the least common restenosis/thrombosis rate in relation to the total number of PCI was in the Ramus intermedius artery.

CONCLUSION

The outcomes of the study indicated that anatomic factors can predict increased risk of restenosis among CAD patients who underwent PCI.

Saphenous Vein Graft Aneurysm after Drug-Eluting Stent Implantation: Treatment by Covered Stent

Saphenous vein graft aneurysms (SVGAs) occur as a rare complication of coronary artery bypass graft but increases the risk of morbidity and mortality. Atherosclerosis is considered to be the most common cause of saphenous vein graft aneurysms. Other etiologies include infections, varicosities of vein grafts, and surgical technical issues. These aneurysms usually present as an incidental finding of a mediastinal or cardiac mass on chest radiograph. Symptomatic aneurysms may present with a wide variety of clinical manifestations such as chest pain/angina, shortness of breath, and myocardial infarction. Treatment options of SVG aneurysms include surgery, percutaneous intervention (including vascular plugs, covered stents, and embolization coils), and conservative management. Herein, we describe a case of a saphenous vein graft aneurysm that developed after percutaneous intervention, which has never been described, to our knowledge, in the previous literature. The aneurysm was treated with polytetrafluoroethylene covered stent implantation.

Coronary Artery Aneurysm in Kawasaki Disease: Coronary CT Angiography through the Lens of Pathophysiology and Differential Diagnosis

Kawasaki disease (KD) is an inflammatory autoimmune vasculitis affecting the coronary arteries of very young patients, which can result in coronary artery aneurysms (CAAs) with lifelong manifestations. Accurate identification and assessment of CAAs in the acute phase and sequentially during the chronic phase of KD is fundamental to the treatment plan for these patients. The differential diagnosis of CAA includes atherosclerosis, other vasculitic processes, connective tissue disorders, fistulas, mycotic aneurysms, and procedural sequelae. Understanding of the initial pathophysiology and evolutionary arterial changes is important to interpretation of imaging findings. There are multiple applicable imaging modalities, each with its own strengths, limitations, and role at various stages of the disease process. Coronary CT angiography is useful for evaluation of CAAs as it provides assessment of the entire coronary tree, CAA size, structure, wall, and lumen characteristics and visualization of other cardiothoracic vasculature. Knowledge of the natural history of KD, the spectrum of other conditions that can cause CAA, and the strengths and limitations of cardiovascular imaging are all important factors in imaging decisions and interpretation. Keywords: Pediatrics, Coronary Arteries, Angiography, Cardiac © RSNA, 2021.

Progressive growth of coronary aneurysms after bioresorbable vascular scaffold implantation: Successful treatment with OCT-guided exclusion using covered stents

The development and progressive enlargement over time of multiple saccular coronary artery aneurysms (CAA) after implantation of everolimus‐eluting stent and bioresorbable vascular scaffolds (BVS) have been reported. CAA was successfully excluded by two overlapped covered stents expanded inside a long metallic drug‐eluting stent to avoid dislodgment at the overlap point. Optical coherence tomography (OCT) was repeatedly performed to monitor CAA expansion and to guide treatment through precise measurement of aneurysm length and vessel size at the landing zone. At 10‐month follow‐up, coronary computed tomography angiography showed persistent CAA exclusion. To the best of our knowledge, this is the first report of this technique to exclude a long CCA segment.

Unusual Presentation of a Rapidly Progressive Coronary Artery Pseudoaneurysm after Drug Eluting Stent Placement

Infected coronary artery aneurysm (CAA) is a rare complication of percutaneous coronary intervention (PCI) and is associated with high morbidity and mortality. The management of infected CAA is unclear and is based on the clinical and imaging features. We report an interesting case of a giant infected right CAA secondary to Pseudomonas aeruginosa within four weeks of a drug eluting stent (DES) implantation. Chronological analysis of the coronary angiograms and computed tomography coronary angiography revealed rapid progression in the size of the aneurysm from small to a giant CAA over a period of four weeks. Patient remained afebrile throughout the hospital stay without any signs of septicaemia. In view of the rapid progression in size, surgical aneurysmal ligation with distal revascularisation was done with good post-operative recovery. Afebrile presentation of an infected CAA is very rarely reported in the literature as in our case. Early diagnosis using multimodality imaging and immediate surgical intervention are the cornerstone in the management of giant infected CAAs.

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.

Percutaneous Coronary Intervention in Coronary Artery Aneurysms; Technical Aspects. Report of Case Series and Literature Review

Coronary Artery Aneurysms (CAAs) in both symptomatic and asymptomatic patients are associated with poor long-term outcomes. The best treatment option for CAAs remains a subject of debate. The underlying pathology is not well understood, randomised controlled trials and supportive data are lacking and there is no consensus on treatment plan. The recommended therapies include medical management, percutaneous or surgical exclusion of the aneurysm or coronary artery bypass grafting surgery (CABG). Percutaneous coronary intervention (PCI) can be technically challenging even with a suitable anatomy, specifically in acute coronary syndrome (ACS). We report case series of CAAs presenting as ACS and focus on PCI treatment option.

Coronary Artery Aneurysm After Drug-Eluting Stent Implantation Causing Coronary-Bronchial Fistula

Coronary artery aneurysm (CAA) after drug-eluting stent implantation is rare, with a reported incidence of 0.3% to 6.0%. Most of these aneurysms are asymptomatic. Hemoptysis as a presentation of CAA is very rare. The patient in our case had CAA after zotarolimus-eluting stent implantation and presented with hemoptysis resulting from a leaking coronary-bronchial fistula. (Level of Difficulty: Intermediate.).

Vascular Stents Coated with Electrospun Drug-Eluting Material: Functioning in Rabbit Iliac Artery

A stenting procedure aimed at blood flow restoration in stenosed arteries significantly improves the efficiency of vascular surgery. However, the current challenge is to prevent neointimal growth, which reduces the vessel lumen, in the stented segments in the long run. We tested in vivo drug-eluting coating applied by electrospinning to metal vascular stents to inhibit the overgrowth of neointimal cells via both the drug release and mechanical support of the vascular wall. The blend of polycaprolactone with human serum albumin and paclitaxel was used for stent coating by electrospinning. The drug-eluting stents (DESs) were placed using a balloon catheter to the rabbit common iliac artery for 1, 3, and 6 months. The blood flow rate was ultrasonically determined in vivo. After explantation, the stented arterial segment was visually and histologically examined. Any undesirable biological responses (rejection or hemodynamically significant stenosis) were unobservable in the experimental groups. DESs were less traumatic and induced weaker neointimal growth; over six months, the blood flow increased by 37% versus bare-metal stents, where it increased by at least double the rate. Thus, electrospun-coated DESs demonstrate considerable advantages over the bare-metal variants.

Multimodal Imaging of Post-Stenting Mycotic Coronary Pseudoaneurysm Complicated by Device Fracture and Myocardial Abscess

Mycotic coronary aneurysm and pseudoaneurysm are rare infective complications of percutaneous coronary interventions, associated with poor prognosis. Multimodality imaging is recommended to achieve a correct diagnosis. We present a case of post-stenting mycotic coronary pseudoaneurysm complicated by myocardial abscess in which we used different imaging tools, each carrying additional information. (Level of Difficulty: Advanced.)

Coronary pseudoaneurysm 1 week after complex percutaneous coronary intervention with drug-eluting stent

Pseudoaneurysm formation is a rare complication after complex PCI with drug-eluting stents. Cardiologists and interventionist should be familiar with this rare complication after PCI and its management options.

Right Coronary Artery Pseudoaneurysm With Hemopericardium: A Rare Complication of Percutaneous Coronary Intervention

While percutaneous coronary intervention (PCI) is a commonly performed procedure, it still has many serious complications. Coronary artery pseudoaneurysms can form after PCI and can progress to cardiac tamponade. We report the case of an 80-year-old male who presented for an inferior wall ST elevation myocardial infarction, had drug-eluting stents placed to the right coronary artery (RCA), and subsequently suffered a RCA pseudoaneurysm with hemopericardium. He eventually underwent pseudoaneurysm repair with off pump coronary artery bypass graft. There is no established treatment protocol, and involvement of a multidisciplinary team improves outcomes.

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.