Coil embolization for distal left main aneurysm: a new approach to coronary artery aneurysm treatment

Coils embolization use for coronary procedures: Basics, indications, and techniques

The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered.

Coronary Artery Aneurysm: Its Evaluation in a 27-Year-Old Female Patient, Prognosis, and Suggested Treatment Strategies

Coronary artery aneurysm (CAA) is characterized by a localized dilation of one or more of the coronary arteries with multiple etiologies, including congenital, acquired, or connected to auto-inflammatory diseases with multiple shapes and classifications. It is usually diagnosed incidentally during coronary imaging and can have variable clinical outcomes, ranging from asymptomatic to sudden cardiac death with a generally poor prognosis. Management of this condition faces a clinical dilemma due to the lack of clear guidelines or randomized trials. Treatment should be individualized based on symptoms, shape, and comorbidities. Herein, we present the case report of a 27-year-old female patient with no prior medical conditions. However, she presented with palpitations, and a compressive mass located over the right atrium was identified in the patient. After undergoing cardiac catheterization and coronary scanning, a giant aneurysm of the sinoatrial branch was detected with an aneurysmal left main that was retrieved surgically with good recovery and postoperative course.

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 non-invasive 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.

"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.

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.

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.

Coronary artery aneurysm: A review

Coronary artery aneurysm (CAA) is a clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold diameter of the adjacent normal segment. Atherosclerosis is the main cause in adults and Kawasaki disease in children. CAA is a silent progressive disorder incidentally detected by coronary angiography, but it may end with fatal complications such as rupture, compression of adjacent cardiopulmonary structures, thrombus formation and distal embolization. The pathophysiological mechanisms are not well understood. Atherosclerosis, proteolytic imbalance and inflammatory reaction are involved in aneurysmal formation. Data from previously published studies are scarce and controversial, thereby the management of CAA is individualized depending on clinical presentation, CAA characteristics, patient profile and physician experience. Multiple therapeutic approaches including medical treatment, covered stent angioplasty, coil insertion and surgery were described. Herein, we provide an up-to-date systematic review on the pathophysiology, complications and management of CAA.

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.

A rare case of stent-assisted coil embolization of coronary artery aneurysm in the left main trigeminal position: Case report

RATIONALE

Coronary artery aneurysms (CAAs) are uncommon in patients with acute coronary syndrome (ACS). We describe the clinical features and outcomes of stent-assisted coil embolization of a CAA in the trigeminal position.

PATIENT CONCERNS

We present a 73-year-old woman with a history of paroxysmal episodes of precordial pain since 1 year. Coronary computed tomography angiography (CTA) revealed an aneurysm (diameter: 9 mm) at the junction of the distal left main coronary artery and the anterior descending branch. Troponin I, CK-MB, creatinine and routine blood investigations were within the normal range.

DIAGNOSIS

Coronary artery aneurysm in the left main trigeminal position.

INTERVENTIONS

The patient was treated with stent-assisted coil embolization.

OUTCOMES

After complete filling of the aneurysm with coil, the microcatheter was withdrawn and the stent released in the descending branch. Two stents were successfully implanted.

LESSONS

There is no clear consensus on the optimal therapy for patients with CAAs. Clinicians should be aware of the possible complications of stent-assisted coil embolization of CAA in the main trunk of the coronary artery.

Coronary Artery Aneurysm: Evaluation, Prognosis, and Proposed Treatment Strategies

Coronary artery aneurysm is a rare disorder, which occurs in 0.3%-4.9% of patients undergoing coronary angiography. Atherosclerosis accounts for >90% of coronary artery aneurysms in adults, whereas Kawasaki disease is responsible for most cases in children. Recently, with the advent of implantation of drug-eluting stents, there are increasing reports suggesting stents causing coronary aneurysms, months or years after the procedure. The pathophysiology of coronary artery aneurysm is not completely understood but is thought to be similar to that for aneurysms of larger vessels, with the destruction of arterial media, thinning of the arterial wall, increased wall stress, and progressive dilatation of the coronary artery segment. Coronary angiography remains the gold standard tool, providing information about the size, shape, and location and is also useful for planning the strategy of surgical resection. The natural history and prognosis remain unclear. Despite the important anatomical abnormality of the coronary artery, the treatment options of coronary artery aneuryms are still poorly defined and present a therapeutic challenge. We describe four cases, which were managed differently followed by a review of the current literature and propose some treatment strategies.

Coil embolization of pseudoaneurysm as a complication of excimer laser coronary angioplasty: insights from intravascular ultrasound and optical coherence tomography findings

The occurrence of pseudoaneurysm in the coronary artery is rare and can develop after percutaneous coronary interventions. To date, the optimal therapy, including conservative, surgical, and endovascular therapies, for pseudoaneurysm in the coronary artery remains unclear. Here, we report a case of pseudoaneurysm arising as a complication of excimer laser coronary angioplasty, which was successfully treated with stent-assisted coil embolization, after which optical coherence tomography revealed complete healing of the pseudoaneurysm. This report highlights the feasibility of stent-assisted coil embolization for coronary pseudoaneurysms involving bifurcation.

Self-apposing stent-assisted coil embolization for the treatment of coronary artery aneurysm

Coronary artery aneurysms (CAA) represent an uncommon disease with yet unclear standards of treatment. Clinical and anatomic characteristics determine choice of treatment. Stent-assisted coil embolization has been described as a valuable option for management of patients with wide-neck coronary aneurysms. Choice of appropriate stent sizing can be challenging particularly when there is a large difference between proximal and distal diameters. We report a case of stent-assisted coil embolization of a coronary aneurysm using a self-expandable stent. This type of stent can be helpful to treat CAA involving coronary sites where marked tapering of vessel diameter is often present.

Unexpected evolution of a non-stenotic lesion in the left main coronary artery of a patient with non-ST-segment elevation myocardial infarction

A 72-year-old man was referred to our catheterization laboratory 48 hours after a non-ST-segment elevation myocardial infarction. His medical history included coronary artery disease (CAD) (percutaneous coronary intervention of the right coronary artery and chronic total occlusion of the circumflex artery), atrial fibrillation (AF), and chronic kidney disease. An electrocardiogram showed a pre-existent left bundle-branch block and the patient's maximum cardiac troponin concentration was 8.64 µg/L (upper limit of normal: 0.003 µg/L). The coronary angiogram revealed an ulcerated plaque of the left main coronary artery (LMCA) and moderate stenosis of the left anterior descending (LAD) coronary artery. A non-interventional approach to treatment was chosen. One month later, a control angiography showed a giant distal aneurysm complicating the lesion; the fractional flow reserve (FFR) value in the LAD was 0.74. The heart team discussed the case and concluded that the aneurysm was inaccessible via surgery. To protect the LAD from possible covered stent thrombosis or restenosis, coronary artery bypass grafting of the LAD was performed prior to percutaneous coronary intervention (PCI). Five days later, we proceeded with percutaneous exclusion of the aneurysm. We combined coil embolization of three Interlock™ two-dimensional detachable coils with stenting of the LMCA, using a PK Papyrus™ covered stent. Effective angiographic exclusion was achieved. The patient was discharged on warfarin, aspirin, and clopidogrel for 1 month, followed by long-term aspirin and oral anticoagulation. A 6-month follow-up angiography demonstrated a completely sealed aneurysm and optical coherence tomography (OCT) confirmed the successful endothelialization of the covered stent.

Coronary Artery Aneurysms: A Review of the Epidemiology, Pathophysiology, Diagnosis, and Treatment

Coronary artery aneurysms (CAAs) are uncommon and describe a localized dilatation of a coronary artery segment more than 1.5-fold compared with adjacent normal segments. The incidence of CAAs varies from 0.3 to 5.3%. Ever since the dawn of the interventional era, CAAs have been increasingly diagnosed on coronary angiography. Causative factors include atherosclerosis, Takayasu arteritis, congenital disorders, Kawasaki disease (KD), and percutaneous coronary intervention. The natural history of CAAs remains unclear; however, several recent studies have postulated the underlying molecular mechanisms of CAAs, and genome-wide association studies have revealed several genetic predispositions to CAA. Controversies persist regarding the management of CAAs, and emerging findings support the importance of an early diagnosis in patients predisposed to CAAs, such as in children with KD. This review aims to summarize the present knowledge of CAAs and collate the recent advances regarding the epidemiology, etiology, pathophysiology, diagnosis, and treatment of this disease.

Percutaneous closure of a coronary artery-to-vein graft anastomotic pseudoaneurysm presenting as acute coronary syndrome after recent coronary artery bypass grafting

Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described. We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery-saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization.

Left main aneurysm and what's next?

The purpose of the case report is to present a case of a 65-year-old male, referred for coronary angiography because of a typical chest pain. The coronary angiography showed an aneurysm of the left main coronary artery. Despite the absence of obvious ischemic symptoms and because of the potential complications of the aneurysm with a width of 15 mm, the patient underwent surgery.

Coronary artery aneurysms: case report and review of transcatheter management strategies

There is no consensus on the best management of coronary artery aneurysms (CAA) in adults. We describe two patients with CAA and review transcatheter approaches to exclude them from the circulation.