Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review

A surgical case report of off-pump onlay patch grafting for pseudoaneurysm with diffusely calcified coronary artery

Coronary pseudoaneurysm usually occurs after catheter-based intervention as a result of traumatic dissection or perforation of a coronary artery in 4%-5% of cases. Here, we report the successful case of pseudoaneurysm occurring after percutaneous coronary angioplasty (PTCA) against the severely calcified coronary artery treated with off-pump long onlay patch bypass technique using internal thoracic arteries. We report the case of a 59-year-old woman treated with off-pump onlay patch grafting for pseudoaneurysm after coronary angioplasty against the diffusely calcified coronary lesion. The portion of the endoarterectomized left anterior descending coronary artery proximal to the resected aneurysm extending 5cm distally was successfully reconstructed with long onlay patch using the internal thoracic arterial graft.

Clinical indications for intravascular ultrasound imaging

Intravascular ultrasound (IVUS) is a catheter-based imaging modality, which provides high resolution cross-sectional images of the coronary arteries. Unlike angiography, which displays only the opacified luminal silhouette, IVUS permits imaging of both the lumen and vessel wall and allows characterization of the type of the plaque. Although IVUS provides accurate quantitative and qualitative information regarding the lumen and outer vessel wall, it is not routinely used during coronary angiography or in angioplasty procedures because the risk to benefit ratio (additional expense, procedural time, certain degree of risk, and complication versus improvement in the outcome) does not justify routine utilization. Nevertheless, there are situations where IVUS is extremely useful tool both for diagnosis and management so the aim of this review is to summarize the indications for IVUS imaging in the contemporary clinical practice.

Coronary artery aneurysms and ectasia: role of coronary CT angiography

Coronary artery dilatations-aneurysms and ectasia-are an uncommon and frequently unrecognized incidental finding in patients with coronary artery disease. Aneurysms and ectasia are associated with a vast group of disorders, and the evaluation and characterization of coronary aneurysms and ectasia represent a great diagnostic task with clinical and therapeutic implications. The underlying etiology is variable and includes degenerative, congenital, inflammatory, infectious, toxic, and traumatic causes. Unlike aneurysms, ectasia is more frequently seen in association with atherosclerosis or as a compensatory mechanism in those cases in which a proximal stenosis is noted in the opposite coronary artery; ectasia is also seen in some coronary artery anomalies, such as anomalous origin from the pulmonary artery, or as a result of a high-flow state, as seen in coronary artery fistulas. The diagnostic approach depends on the clinical scenario, and nowadays, noninvasive evaluation with multidetector computed tomography is possible. Imaging assessment should include evaluation of (a) the distribution, (b) maximal diameter, (c) presence or absence of intraluminal thrombi, (d) number, (e) extension, and (f) associated complications such as myocardial infarction. This article presents an overview of the definition, classification, etiology, clinical manifestations, and potential complications of coronary artery aneurysms and ectasia.

Spontaneous coronary artery dissection: a Western Denmark Heart Registry study

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that associates with a high acute-phase mortality rate, whereas long-term outcome is less well described.

OBJECTIVE

To describe the incidence, predictors, and prognosis of SCAD.

DESIGN

Retrospective case-identification study from the Western Denmark Heart Registry and the database of the Forensic Institute at Aarhus University from 1999 through 2007.

RESULTS

SCAD was documented in 22 of 32,869 (0.7 per thousand) angiograms in the angiographic registry. The SCAD incidence among cases of ACS was 22 of 11,175 (2.0 per thousand). None was seen in the forensic database. The mean age was 48.7 +/- 8.9 years (range: 37-71 years). Females constituted 17 of 22 (77%) patients and all had undergone one or more pregnancies; two cases occurred in the postpartum period. The left descending artery (LAD) was the predominant site of entry. The age distribution, prevalence of the cardiovascular risk factors, presence of coronary atherosclerosis, and entry of the dissection were comparable among genders. Treatment was percutaneous coronary intervention in 13 of 22 (59%), coronary artery bypass operation in 2 of 22 (9%), and medical treatment in 7 of 22 (32%) patients. The mean follow-up period was 3.6 +/- 2.9 years. One patient suffered from recurrent SCAD; another patient died suddenly. The MACE- (cardiac death, nonfatal myocardial infarction, and new revascularization) free survival was 81% after 24 months.

CONCLUSION

SCAD is a rare disease that mainly affects younger women. Compared with earlier reports, the prognosis seems to be improved by early diagnosis and interventional treatment.

Natural history of a giant coronary aneurysm with spontaneous dissection

Primary spontaneous coronary artery dissection may appear in young women during the peripartum period or as a result of atherosclerosis. We present a patient with familial hypercholesterolemia who developed a giant aneurysm of the right coronary artery in the setting of atherosclerotic spontaneous coronary dissection over an 8 year period. This report illustrates the association between spontaneous coronary artery dissection and subsequent coronary aneurysm formation.

Spontaneous left main coronary artery dissection complicated by pseudoaneurysm formation in pregnancy: role of CT coronary angiography

We report a case of a 26-year-old female, who presented at 34 weeks of an uncomplicated pregnancy with an acute ST elevation anterior wall myocardial infarction. Cardiac catheterization suggested a left main coronary artery dissection with pseudoaneurysm formation. The patient's course was complicated by congestive heart failure. She was initially managed conservatively by a multidisciplinary team including heart failure specialists, obstetricians, and cardiovascular surgeons. 4 days after admission, her LMC was imaged by dual-source 64 slice Cardiac computed tomography, coronary dissection was identified extending to the lumen, and the presence of pseudoaneurysm was confirmed. She underwent subsequently a staged procedure, which included placement of an intra-aortic balloon pump, cesarean section, and coronary artery bypass grafting. This case illustrates the utility of coronary artery CT imaging to assess the complexity and stability of coronary artery dissections, thereby helping to determine the need for, and timing of revascularization procedures.

Giant coronary artery aneurysm associated with medial mucoid degeneration

A 52-year-old man underwent surgical repair for coronary arteriovenous fistula including patch closure of two exitus of the fistula, double ligation of the dilated right coronary artery, and coronary bypass grafting to the right coronary artery with saphenous vein graft at the age of 25. Then, twenty-seven years later, a multi-detector computed tomographic scan revealed an aneurysmally dilated right coronary artery (4.8 cm), fistula, and saphenous vein graft. The aneurysm was resected and histologically mucoid degeneration in the media of the aneurysmal wall was detected.

Coronary artery aneurysm with thrombus evaluated by multi-detector row computed tomography

This is a case report of a 60-year-old woman with acute myocardial infarction (AMI) who had coronary aneurysms and thrombus in the right coronary artery detected by multi-detector row computed tomography (MDCT). In this case, MDCT was useful for clarifying the thrombus complicated with coronary aneurysms, which was considered to be the cause of AMI. Thus, warfarin was started as an anticoagulant therapy for thrombus.

Pathogenetic mechanisms of coronary ectasia

Coronary ectasia is defined as local or generalized aneurysmal dilatation of the coronary arteries. The present review summarizes the molecular, cellular and vascular mechanisms which are involved in the pathobiology of coronary ectasia. Coronary ectasia likely represents an exaggerated form of expansive vascular remodeling (i.e. excessive expansive remodeling) in response to atherosclerotic plaque growth. Enzymatic degradation of the extracellular matrix of the media is the major pathophysiologic process that leads to ectasia. Atherosclerotic lesions within ectatic regions of the coronary arteries appear to be highly inflamed high-risk plaques with proclivity to rupture. Better understanding of the pathogenetic processes involved in coronary ectasia is anticipated that will provide a further insight into the clinical significance and natural history of this entity, and may also have direct clinical implications in the management and follow-up strategy of this condition.

Right coronary artery aneurysm: Possible relation with obesity?

Aneurysms of the coronary arteries are uncommon occurrences that usually develop secondary to atherosclerosis and are often asymptomatic. We present a 57-year-old male patient who presented with the diagnosis of an inferior wall acute myocardial infarction with a large aneurysm of the right coronary artery and with morbid obesity. To the best of our knowledge, a relationship between body mass index and coronary artery aneurysm has not been reported in the literature so far. We speculated that there is a relationship between coronary artery aneurysm and body mass index.

Spontaneous dissection of the distal obtuse marginal coronary artery: a rare cause of sudden death

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden death. It typically, but not always, occurs in healthy postpartum women without traditional risk factors for atherosclerosis. Moreover, the site of dissection usually involves the proximal, major coronary arteries: left main coronary artery and/or the left anterior descending artery, and in men, more often the right coronary artery. We report a case of sudden death caused by dissection of the obtuse marginal branch of the left circumflex artery, in a 49-year-old man, a very rare site of fatal coronary dissection.

Iatrogenic right coronary artery dissection with retrograde extension to the right coronary sinus

Iatrogenic coronary artery dissection extending into the aorta is a rare condition. We report a case in a 46-year-old male patient who had dissection of the right coronary artery which occurred during diagnostic coronary catheterization. The dissection extended retrogradely to affect the right coronary sinus. The patient was treated successfully by coronary artery bypass grafting with repair of the aortic dissection.

Catheter-Induced Left Main Coronary Artery Spiral Dissection: Stenting or Bypass? (Case Report and Literature Review)

Catheter-induced Left Main Coronary Artery (LMCA) dissection is a very uncommon but life-threatening complication of coronary intervention and requires urgent management. We report one such patient whose risk factors appear to be Coronary Artery Disease (CAD), smoking and a prior Myocardial Infarction (MI).

Spontaneous right coronary artery pseudoaneurysm

A 67-year-old man who had no history of coronary artery disease was found to have electrocardiographic abnormalities. Coronary angiography showed a proximal coronary artery aneurysm and total occlusion of the distal right coronary artery. He underwent coronary artery bypass grafting and repair of the right coronary artery aneurysm. The pathology of the resected aneurysm wall was compatible with a diagnosis of coronary pseudoaneurysm. Spontaneous coronary artery pseudoaneurysm is a rare condition that has the potential risk of rupture or ischemia. Surgical repair and adequate coronary revascularization are reasonable for a possible coronary artery pseudoaneurysm.

Spontaneous coronary artery dissection and pulmonary thromboembolism: a case report

Spontaneous coronary artery dissection (SCAD) still is a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, peripartal women and idiopathic group. SCAD may be associated with some conditions. We report an unusual association: SCAD and pulmonary thromboembolism.

Search your heart for a cause of syncope!

A 66-year-old female presented to casualty with recurrent syncopal episodes and a history of ischaemic heart disease. Initial investigations did not provide a definitive diagnosis. Subsequent CT scanning identified a giant pseudoaneurysm of the left anterior descending coronary artery, which is the largest reported to date. We include a short discussion on current literature surrounding coronary artery pseudoaneurysmal disease.

Coronary artery aneurysm: a review

Coronary artery ectasia (CAE) is found in 0.3-5% of patients undergoing coronary angiography. Atherosclerosis is the main cause, followed by Kawasaki disease and infectious emboli. The exact pathogenesis has not been diagnosed as yet, but an inflammatory process is underlying. Symptoms, if present, are usually related to myocardial ischemia. Angiography is the mainstay for diagnosis. The prognosis is generally favorable. Thromboembolic complications are rare with antiplatelet therapy, and spontaneous rupture generally is rare but occurs more commonly in Kawasaki disease. Management varies from antithrombotic therapy to surgical ligation. Controlling coronary heart disease risk factors sharply affects the prognosis in patients with CAE.

Coronary Pseudoaneurysm: An Unreported Complication of Castleman’s Disease

Castleman's disease is considered a benign disease with very few reports of local invasion into adjacent structures. We present the first reported case of myocardial involvement with Castleman's disease. Careful preoperative planning allowed the placement of a left ventricular assist device with eventual heart transplantation after complete resection of the tumor and unsuccessful myocardial revascularization.

Spontaneous coronary artery dissection after heavy lifting in a 25-year-old man with coronary risk factors

Spontaneous coronary artery dissection (SCAD) is a clinical condition rarely leading to acute myocardial infarction (AMI). We report the case of SCAD presenting AMI in a 25-year-old man with coronary risk factors after strenuous exercise, who was successfully treated with systemic thrombolysis. Coronary angiography revealed spiral dissection of the proximal part of the left anterior descending artery. The present case supports the occurrence of SCAD as a cause of AMI in young male patients who have coronary risk factors, after heavy lifting.

A giant coronary artery aneurysm in the right coronary artery

Aneurysms of the coronary arteries are uncommon occurrences that usually develop secondary to atherosclerosis and are often asymptomatic. They are usually diagnosed incidentally during investigation for ischemic heart disease or at autopsy for sudden death. We present a case of a "giant" right coronary artery aneurysm (CAA) discovered incidentally at surgery. Pathological examination confirmed that this was a true aneurysm showing marked thinning of the media and fibrocalcific plaques with small, multifocal areas of lymphocytic infiltrates.

Cardiac Tamponade Caused by Acute Spontaneous Coronary Artery Rupture

Acute spontaneous coronary artery rupture is rare and the diagnosis might be missed due to high risk of mors subita. We present three patients hospitalized with signs of cardiac tamponade due to acute spontaneous coronary artery rupture. All the three were successfully operated with evacuation of the pericardial hematoma, identification of the bleeding site, and hemostasis. The patients were examined with coronary angiography and computer tomography, and no underlying cause of the rupture was detected. In patients presenting with cardiac tamponade, acute spontaneous coronary artery rupture is a possible diagnosis.

Stent-assisted detachable coil embolization of pseudoaneurysms in the coronary circulation

Pseudoaneurysms in the coronary circulation are an uncommon occurrence that can develop spontaneously in the setting of atherosclerosis or can develop after catheter-based coronary interventions. The natural history, clinical outcome, and optimal therapy for pseudoaneurysms in the coronary circulation are not clearly established. Recent advances in the techniques and technologies used for endovascular treatment of intracranial aneurysms may be applicable to the management of coronary aneurysms and pseudoaneurysms. We present a case of spontaneous coronary pseudoaneurysm formation after paclitaxel drug-eluting stent implantation and a case of pseudoaneurysm formation in a saphenous vein graft that were both successfully treated with stent-assisted detachable coil embolization.