Coil embolization of a circumflex coronary aneurysm at the time of percutaneous coronary stenting

Primary coronary artery pseudoaneurysm in a patient with familial hypercholesterolemia

Rare primary coronary artery pseudoaneurysms in a young patient with heterozygous FH was successfully repaired with direct closure of intimal defects with aneurysmorrhaphy.

Technical Considerations of Giant Right Coronary Artery Aneurysm Exclusion

Giant coronary artery aneurysms are rare clinical entities. We report the case of a 49-year-old man who presented with dyspnoea and exertional chest pain. Investigations confirmed an aneurysmal right coronary artery measuring 4 cm with a fistulous communication to the right atrium. Following right atriotomy, the fistula was oversewn and the aneurysmal right coronary artery ligated at its origin and at several points along its course. A saphenous vein graft was anastomosed to the posterior descending artery. Persistent ventricular fibrillation occurred upon chest closure, attributed to ischaemia following ligation of the aneurysmal coronary artery. Emergent resternotomy and internal defibrillation were successfully performed. The sternum was stented open to reduce right ventricular strain and closed the following day. The patient made an unremarkable recovery. We here address the technical challenges associated with surgical repair of right coronary aneurysms and the physiology and management of potential complications.

Giant Right Coronary Artery Aneurysm Mimicking a Mediastinal Cyst With Compression Effects: A Case Report

Introduction

Giant coronary artery aneurysm is an extremely rare form of coronary artery disease. The most common cause of coronary artery aneurysms is atherosclerosis. Although it is usually asymptomatic, it may have various clinical presentations, including angina, myocardial infarction or sudden death.

Case Presentation

A 32-year-old woman presented with edema of the upper and lower limbs, palpitation, and chest pain, and was diagnosed with a giant right coronary artery aneurysm that had initially mimicked a mediastinal cyst. Although computed tomography (CT) suggested a mediastinal cyst, trans-thoracic echocardiography revealed an extra pericardial cyst. The definitive diagnosis of right coronary artery aneurysm was made based on CT angiography and coronary angiography findings. As treatment, aneurysmectomy was performed, and she was discharged on the sixth postoperative day with good general health condition.

Conclusions

Coronary artery aneurysm should be a differential diagnosis in cases of mediastinal cyst and mass lesion.

Coil embolization of left coronary artery pseudoaneurysms arising as a complication of percutaneous coronary intervention

Coronary aneurysms and pseudoaneurysms have been described as rare complications following percutaneous coronary intervention (PCI). There is limited data available on the optimal treatment strategy for these conditions. Use of noninvasive techniques including covered stents has been described as a potential therapeutic strategy. We report a case of percutaneous coil embolization of two enlarging left anterior descending pseudoaneurysms arising as a complication of PCI.

Spontaneous rupture of a giant coronary artery aneurysm causing cardiac tamponade: A case report

A 62-year-old woman with a history of dyslipidemia and hypothyroidism was referred to our institution with syncope. Cardiac tamponade due to spontaneous rupture of a 50-mm aneurysm of the coronary artery was diagnosed by transthoracic echocardiography, enhanced computed tomography, and coronary angiography. Emergency surgery was performed, and despite developing postoperative complications such as acute renal insufficiency, the patient was discharged from hospital without sequelae 89 days later. Histological findings revealed cystic media degeneration, but neither significant atherosclerotic changes nor inflammatory cell infiltration. Although coronary artery aneurysms are comparatively rare and generally asymptomatic, those over 30 mm in diameter are considered to be at increased risk of rupture. A coronary artery aneurysm of about 50 mm ruptured in our patient, supporting this view.

Acute hemodynamic changes in percutaneous transluminal septal coil embolization for hypertrophic obstructive cardiomyopathy

BACKGROUND

A 48-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) presented with palpitations, symptoms of medically refractory class II angina, and NYHA class II-III heart failure.

INVESTIGATIONS

Physical examination revealed a grade 3 systolic murmur that increased to grade 4 with exercise. Echocardiography showed marked septal thickening (17 mm), a left ventricular outflow tract gradient (LVOTG) of 95 mmHg, and a 3+ systolic anterior motion of the mitral valve apparatus. No other pathology was noted with cardiac MRI or with coronary angiography.

DIAGNOSIS

Severe symptomatic HOCM.

MANAGEMENT

Coil embolization of the first two septal vessels resulted in a limited septal infarct (creatine kinase-MB 36.6 microg/l; troponin T 0.43 microg/l) that corresponded to a mass of 8.1 g on gadolinium contrast cardiac MRI. The LVOTG decreased immediately from 78 mmHg to 35 mmHg. On pressure-volume loops, contractile isovolemic and systolic ejectional parameters decreased, while an improvement in diastolic left ventricular function was observed.

CONCLUSION

Septal coil embolization acutely and effectively reduced the LVOTG in a patient with drug-refractory HOCM.

Coronary artery aneurysm: a review and hypothesis regarding etiology

CONTEXT

Coronary artery aneurysm is an uncommon condition that can be a cause of death when it thromboses or ruptures. It is always associated with destruction of the tunica media, usually associated with atherosclerosis, and commonly associated with chronic inflammation.

OBJECTIVE

To review the pathology, epidemiologic and clinical features, and pathophysiology of coronary artery aneurysm, particularly new research results, drawing out implications for the understanding, diagnosis, and treatment of this condition.

DATA SOURCES

Pertinent literature and illustrative cases at our institution.

CONCLUSIONS

Inflammation spilling over into the tunica media from the tunica intima may link atherosclerosis to aneurysm formation, but vasculitis without atherosclerosis causes coronary artery aneurysms in young children with Kawasaki disease. Increased proteolysis of extracellular matrix proteins is probably one mechanism of coronary artery aneurysm formation, either due to overactive matrix metalloproteinases or underactive inhibition of these proteinases, and an excess of transforming growth factor beta may be another mechanism in the pathogenesis. Coronary atherosclerosis is a universal disease of adults, but only 1.5% of them have coronary aneurysms; this small group may be those with a second coronary artery disease, such as vasculitis.

Use of stent grafts and coils in vessel rupture and perforation

Vessel rupture and perforation are important complications of percutaneous treatment of coronary and peripheral arterial disease. These complications can result in abrupt vessel closure, distal organ injury, bleeding into the surrounding tissue, and death. Prompt management of such complications is therefore critically important. This paper reviews the management of vessel rupture and perforation, including the use of different types of covered stents (balloon-expandable and self-expanding), as well as the various types of embolization coils. Particular focus will be placed on percutaneous coronary artery and peripheral arterial interventions.

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.