Atherosclerotic ulcerative disease and associated aneurysms of the coronary arteries

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Case Report: Not a Mediastinal Mass! a Ruptured Giant Coronary Aneurysm That Occurred in a Young Man

Introduction

Coronary artery aneurysm (CAA) is a localized coronary artery dilatation that exceeds 1. 5 times the diameter of a standard adjacent segment or the largest coronary vessel. When the expansion is > 2 cm, it is called a “giant” coronary artery aneurysm. Giant coronary artery aneurysm rupture is extremely rare and fatal.

Case presentation

We present a rare case of a 27 years old male with a giant coronary artery aneurysm rupture, but no catastrophic events occurred immediately. He was initially misdiagnosed as having a mediastinal mass with CT (computed tomography). The cardiac ultrasound showed no pericardial effusion. But The cardiac CTA (computed tomography angiography) showed a giant coronary aneurysm rupture with hematoma formation. He eventually underwent surgery and was followed up for 2 months without complications.

Conclusion

We report this case of a ruptured giant coronary aneurysm because of its infrequent occurrence in coronary artery disease. It is tough to distinguish this disease from a mediastinal tumor, and chest MRI and cardiac CTA are crucial tests. Finally, surgical resection may be the right choice for coronary aneurysm rupture. More cases need to be reported to facilitate the preoperative diagnosis of this rare coronary aneurysm.

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.

Management of Coronary Artery Aneurysms at the Time of Surgical Revascularization

BACKGROUND

Coronary artery aneurysms (CAAs) represent a rare pathology occurring in 1.5%-5% of routine coronary angiograms. Limited data exist on the management of CAA at the time of cardiac surgery.

MATERIALS AND METHODS

A single-institution retrospective review was performed on 53 patients who underwent cardiac surgery in the setting of atherosclerotic CAA between 1993 and 2015. Patients were stratified based on treatment strategy: exclusion and distal bypass (n = 26) versus revascularization alone (n = 27). Comparisons were made with respect to mortality, need for further/concomitant interventions, and long-term cardiac function including myocardial infarctions and congestive heart failure.

RESULTS

A total of 53 patients underwent cardiac surgery in the setting of CAA disease. Management strategies included ligation and bypass in 26 patients and distal bypass only in 27 patients (with four of the patients in this group undergoing coronary stenting across the aneurysm). There were no significant differences in patient demographics between the two groups. No significant difference was found in either 30-d (P = 0.74) or long-term mortality when exclusion of the CAA was performed compared with revascularization alone (P = 0.20). More exclusion procedures were performed earlier in the experience (median surgical date 2000), whereas revascularization alone predominated later in the experience (median surgical date 2007; P ≤ 0.001).

CONCLUSIONS

The practice of CAA exclusion, while still performed in selected cases, has largely been supplanted in patients undergoing revascularization. Exclusion does not appear to offer any advantage over isolated revascularization, supporting the current trends in managing this rare condition.

Coronary Aneurysm: An Enigma Wrapped in a Mystery

Coronary aneurysms are defined as localized dilatations of the coronary arteries. In this review, we will analyze the most important aspects of this rare condition while trying to provide answers to the following questions: What is a coronary aneurysm? What causes coronary aneurysm? Do coronary aneurysms cause symptoms? Can coronary aneurysms rupture? How do we treat coronary aneurysms?

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.

Aneurysmal coronary artery disease: An overview

Aneurysmal coronary artery disease (ACAD) comprises both coronary artery aneurysms (CAA) and coronary artery ectasia (CAE). The reported prevalence of ACAD varies widely from 0.2 to 10%, with male predominance and a predilection for the right coronary artery (RCA). Atherosclerosis is the commonest cause of ACAD in adults, while Kawasaki disease is the commonest cause in children and adolescents, as well as in the Far East. Most patients are asymptomatic, but when symptoms do exist, they are usually related to myocardial ischemia. Coronary angiography is the mainstay of diagnosis, but follow up is best achieved using noninvasive imaging that does not involve exposure to radiation. The optimal management strategy in patients with ACAD remains controversial. Medical therapy is indicated for the vast majority of patients and includes antiplatelets and/or anticoagulants. Covered stents effectively limit further expansion of the affected coronary segments. Surgical ligation, resection, and coronary artery bypass grafting are appropriate for large lesions and for associated obstructive coronary artery disease.

Giant right coronary artery (RCA) aneurysm

Coronary artery aneurysm (CAA) is a rare type of coronary artery disease. The angiographic incidence of the coronary artery aneurysm is reportedly between 1.5% to 4.9%, and it is more frequent in men. We have successfully carried out a simultaneous "coronary bypass together with aneurysm ligation" operation on a patient with coronary heart disease and an aneurysm within the right coronary artery.

Incidence and natural history of coronary artery aneurysm developing after drug-eluting stent implantation

AIMS

There is a growing concern about the occurrence of coronary artery aneurysms (CAAs) after drug-eluting stent (DES) implantation and their long-term course. We assessed the occurrence and the factors affecting the long-term outcome of DES-associated CAA.

METHODS AND RESULTS

We analyzed 3,612 consecutive patients (4,419 lesions) who underwent follow-up angiography after DES implantation. All 34 CAAs (0.76% per lesion) in 29 patients (0.8% per patient) were detected at follow-up, and the mean elapsed time from DES implantation to CAA diagnosis was 414 ± 213 days. Angiographically, CAAs developed almost exclusively in complex (type B2/C) de novo lesions (30 [88.2%] of 34 lesions), and lesion length was significantly greater in patients with CAA than without CAA (26.9 ± 9.03 vs 23.1 ± 7.14 mm; P = .004). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA (17.2%), 4 of whom were on aspirin only without clopidogrel.

CONCLUSION

Although CAAs rarely develop after DES implantation and show mostly favorable clinical courses, long-term maintenance of clopidogrel therapy might be required to minimize occurrence of adverse clinical events resulting from stent thrombosis.

Noninvasive assessment of coronary artery ectasia using multidetector computed tomography

OBJECTIVES

The aim of this study is to determine the prevalence of coronary artery ectasia and its relationship to atheromatous changes in participants undergoing coronary computed tomography angiography.

BACKGROUND

Coronary artery ectasia occasionally encountered on conventional coronary angiography is considered a manifestation of atherosclerosis.

METHODS

Four hundred consecutive participants, 300 men (mean age 56 years) who underwent coronary computed tomography angiography were evaluated. Coronary artery ectasia was defined as an arterial segment with a diameter of at least 1.5 times the diameter of the adjacent normal coronary artery. The prevalence and location of coronary artery ectasia as well as concomitant atherosclerotic changes were evaluated. The association of coronary artery ectasia with coronary risk factors was also studied.

RESULTS

Coronary artery ectasia was encountered in 31 participants (8%), 29 men. The right coronary artery was most commonly affected with ectasia (50%) and most participants had single-vessel involvement (74%). Twenty-six of 31 participants (84%) had coexisting atheromatous wall changes or insignificant coronary artery disease; four participants out of 31 (13%) had significant coronary artery disease. Coronary artery ectasia thrombosis was found only in one patient (3%). No apparent correlation was present between coronary artery ectasia and diabetes mellitus, hypertension, hyperlipidemia, smoking and family history of coronary artery disease.

CONCLUSION

The prevalence of coronary artery ectasia in consecutive participants who underwent coronary computed tomography angiography is 8%. The right coronary artery was most commonly affected and most participants had single-vessel involvement. Coronary artery ectasia usually is associated with atheromatous changes, but not with significant coronary artery disease. Coronary artery ectasia thrombosis was a rare complication. No specific predisposing factors have been identified.

Use of polytetrafluoroethylene-covered stent for treatment of coronary artery aneurysm

Coronary artery aneurysm is an uncommon occurrence, yet it is described more often today than in the past as coronary angiography is now routinely used for diagnosis and treatment of ischemic heart disease. However, there is no therapeutic consensus regarding this finding. We present a case of giant coronary artery aneurysm and review the literature on the use of polytetrafluoroethylene-covered stents as a therapeutic option for this condition. Combined antiaggregant therapy is needed after the procedure. Randomized controlled trials of surgery versus covered stents are necessary to define the best treatment for large coronary artery aneurysms.

Increased aortic stiffness in patients with coronary artery ectasia

OBJECTIVE

Alterations in aortic stiffness may reflect the elastic properties of the larger arteries. In many diseases, aortic elastic properties have been investigated to show whether the larger arteries are involved. The elastic properties of aorta in patients with coronary artery ectasia, however, have not been studied yet. We aimed to investigate aortic stiffness parameters in patients with coronary artery ectasia and to compare patients with coronary artery ectasia and coronary artery disease with the control group.

METHOD

Thirty-three patients with coronary artery ectasia, 31 patients with coronary artery disease and 30 patients with angiographically normal coronary arteries were included in this study. Aortic diameters were measured on the M-mode tracing obtained at a level 3 cm beyond the aortic valve at parasternal long-axis view. Aortic diameter change, aortic strain, aortic distensibility and stiffness parameters were measured as aortic stiffness parameters.

RESULTS

Aortic diameter changes were fewer in the coronary artery ectasia and coronary artery disease group than in the control group (0.4 +/- 0.1 and 0.3 +/- 0.1 vs. 0.8 +/- 0.2; P < 0.001). Aortic distensibility and aortic strain were significantly lower in patients with coronary artery ectasia and coronary artery disease than in the controls (for aortic distensibility P < 0.001 and for aortic strain P < 0.001, < 0.001, respectively). In contrast, a significantly higher aortic stiffness index was observed in patients with coronary artery ectasia and coronary artery disease than in the control group (14.2+/-2.6 and 18.1 +/- 2.9 vs. 5.9 +/- 1.8; P < 0.001, respectively).

CONCLUSIONS

The impairment in aortic elastic properties in patients with coronary artery ectasia indicates that this disease is a generalized disease rather than a localized disease of the coronary arteries.

Increased prevalence of coronary artery aneurysms among cocaine users

BACKGROUND

Cocaine abuse has been implicated in multiple cardiovascular complications. Coronary artery aneurysms (CAAs) and ectasia occur in 0.2% to 5.3% of patients referred for angiography and are associated with atherosclerosis, Kawasaki's disease, and several rare disorders. After observing CAAs in multiple young cocaine users, we investigated the prevalence of CAAs among cocaine users undergoing coronary angiography.

METHODS AND RESULTS

Clinical and angiographic characteristics of 112 consecutive patients with a history of cocaine use and coronary angiography were compared with a control group of similar age and risk factors from an existing angiographic database over the same time period. Coronary angiograms were independently read by 3 reviewers blinded to cocaine use. Cocaine users were young (mean age, 44 years), predominantly male (80%), and cigarette smokers (95%). Control patients had higher rates of diabetes (33%) and more severe coronary artery disease (P=0.01). Previous myocardial infarction was common in both groups (45% of cocaine users, 38% of control patients). Despite the frequent history of myocardial infarction among cocaine users, 48% had nonobstructive coronary artery disease. Among cocaine users, 34 of 112 (30.4%) had CAAs compared with 6 of 79 (7.6%) in the control group (P<0.001). Cocaine use was a strong predictor of CAA by univariate and multivariate analyses.

CONCLUSIONS

This is the first description of an association between cocaine use and CAA. The prevalence of CAA among cocaine users was higher than expected (30.4%), given such a young cohort. Cocaine use may predispose to the formation of CAA, which may in turn be a contributing factor to myocardial infarction.

Intravascular ultrasound evaluation of ruptured plaque in the left main coronary artery misinterpreted as an aneurysm by angiography

We report a patient who demonstrated a left main coronary aneurysm by angiography. Intravascular ultrasound (IVUS) revealed that it was in fact an ulceration, which indicated ruptured plaque. This case provides evidence that IVUS can permit a more powerful definition of ruptured plaque than angiography. On IVUS, ulceration exhibits significantly different characteristics from aneurysm.

Incidental echocardiographic detection of coronary artery aneurysm in a patient with multiple vascular aneurysms

This is a case of a 74-year-old male with known multiple peripheral aneurysms. The patient presented for resection of a right popliteal aneurysm. During a routine preoperative transthoracic echocardiography, we detected a cystic structure on the inferolateral aspect of the basal left ventricle and the left atrium along the atrioventricular groove. A CT scan confirmed this to be a left circumflex artery aneurysm. The patient subsequently died of a ruptured berry aneurysm and an intracranial bleed.

Elevated levels of matrix metalloprotein-3 in patients with coronary aneurysm: A case control study

Background

Matrix metalloproteinases (MMPs) have been implicated in the pathogenesis of arterial aneurysms through increased proteolysis of extracellular matrix proteins. Increased proteolysis due to elevated matrix degrading enzyme activity in the arterial wall may act as a susceptibility factor for the development of coronary aneurysms. The aim of this study was to investigate the association between MMPs and presence of coronary aneurysms.

Methods

Thirty patients with aneurysmal coronary artery disease and stable angina were enrolled into study (Group 1). Fourteen coronary artery disease patients with stable angina were selected as control group (Group 2). MMP-1, MMP-3 and C-reactive protein (CRP) were measured in peripheral venous blood and matched between the groups.

Results

Serum MMP-3 level was higher in patients with aneurismal coronary artery disease compared to the control group (20.23 ± 14.68 vs 11.45 ± 6.55 ng/ml, p = 0.039). Serum MMP-1 (13.63 ± 7.73 vs 12.15 ± 6.27 ng/ml, p = 0.52) and CRP levels (4.78 ± 1.47 vs 4.05 ± 1.53 mg/l, p = 0.13) were not significantly different between the groups.

Conclusion

MMPs can cause arterial wall destruction. MMP-3 may play role in the pathogenesis of coronary aneurysm development through increased proteolysis of extracellular matrix proteins.

Relation of matrix-metalloproteinase 3 found in coronary lesion samples retrieved by directional coronary atherectomy to intravascular ultrasound observations on coronary remodeling

We investigated the relation between the presence of matrix-metalloproteinases (MMPs) and direction of remodeling in the coronary lesions of 35 patients. Positive arterial remodeling describes a compensatory expansion of the external elastic membrane (EEM) area of atherosclerotic lesions. An association between positive remodeling and unstable clinical presentation has been previously described. However, the pathophysiology of the remodeling process is not completely understood. Preinterventional intravascular ultrasound images and directional atherectomy (DCA) samples were analyzed. The remodeling ratio was calculated as the EEM area at the lesion site divided by the EEM area at the proximal reference. Positive, intermediate, and negative remodeling were defined as ratios of >1.05, 0.95 to 1.05, and <0.95, respectively. The histologic samples were immunostained for MMP-1, -2, -3, and -9. Positive, intermediate, and negative remodeling was present in 15, 7, and 13 lesions, respectively. Mild and intense cell-associated staining for MMP-1 was found in 21 (68%) and 10 (32%) patients, respectively. Staining for MMP-3 was mild in 20 patients (67%) and intense in 10 patients (33%). Immunostaining for MMP-2 and -9 was mild in all samples. Intense staining for MMP-3 was significantly more common in lesions with positive than negative and/or intermediate remodeling (58% vs 17%; p = 0.04; p = 0.053 after adjustment for gender). Thus, in this in vivo intravascular ultrasound and histologic study, increased cell-associated MMP-3 staining was associated with positive arterial remodeling.

Arterial remodeling and coronary artery disease: the concept of "dilated" versus "obstructive" coronary atherosclerosis

Traditionally, the development of coronary artery disease (CAD) was described as a gradual growth of plaques within the intima of the vessel. The outer boundaries of the intima, the media and the external elastic membrane (EEM), were thought to be fixed in size. In this model plaque growth would always lead to luminal narrowing and the number and severity of angiographic stenoses would reflect the extent of coronary disease. However, histologic studies demonstrated that certain plaques do not reduce luminal size, presumably because of expansion of the media and EEM during atheroma development. This phenomenon of "arterial remodeling" was confirmed in necropsy specimens of human coronary arteries. More recently, the development of contemporary imaging technology, particularly intravascular ultrasound, has allowed the study of arterial remodeling in vivo. These new imaging modalities have confirmed that plaque progression and regression are not closely related to luminal size. In this review, we will analyze the role of remodeling in the progression and regression of native CAD, as well as its impact on restenosis after coronary intervention.

Coronary artery aneurysms: A 25-patient study

Coronary artery aneurysm is a rare disorder, characterized by abnormal dilatation of a localized portion or diffuse segments of the coronary artery. We studied clinical demographics, catheterization findings, and clinical outcomes in an Asian patient cohort with documented coronary artery aneurysms. Compared to a Caucasian adult population, our patient cohort had a lower incidence of coronary artery aneurysm (0.25% vs. 2.6%), and more patients with nonobstructive coronary artery aneurysms (70%); age, gender, and coronary distribution were comparable. The initial presentation of myocardial infarction occurred in five patients (5/17, 30%) with nonobstructive coronary artery aneurysms; however, none who were receiving preventive medications consisting of anticoagulant and antiplatelet agents subsequently developed myocardial infarction. We conclude that the incidence of coronary artery aneurysms with or without associated significant coronary stenosis seems to be lower in the Asian population. In contrast, the incidence of nonobstructive coronary artery aneurysms is considerably high and should not be thought of as a relatively benign disease entity if not treated with preventive medications. Rheumatoid arthritis-related vasculitis might be a cause of coronary artery aneurysm. Surgical intervention is based on the severity of coronary artery stenosis. The result of medical treatment has been compatible with long-term survival. Cathet. Cardiovasc. Intervent. 48:31-38, 1999.

Coronary artery aneurysm: a review

Coronary artery aneurysm is defined as coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. This is an uncommon disease which has been diagnosed with increasing frequency since the advent of coronary angiography. The incidence varies from 1.5% to 5% with male dominance and a predilection for the right coronary artery. Atherosclerosis accounts for 50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture and vasospasm. The natural history and prognosis remains obscure. Controversies persist regarding the use of surgical or medical management. The authors recommend surgery based on the severity of associated coronary stenosis rather than the mere presence of aneurysm. Medical therapy is indicated for the majority of patients and consists of antiplatelet and anticoagulant medication.

Coronary artery aneurysms. Report of two cases and review of the literature

Two patients who had angiographically proven coronary artery aneurysms are presented. The clinical pictures of these patients were similar to that of patients with atherosclerotic coronary artery disease. Both had severe angina pectoris, and the second patient (case 2) had had myocardial infarction. Their coronary artery aneurysms were single, fusiform (case 1) and saccular (case 2) in shape and not associated with extensive coronary atherosclerosis. They were treated medically and did well.

Intravascular ultrasound approach to the diagnosis of coronary artery aneurysms

Coronary artery aneurysms are usually diagnosed by contrast coronary angiography, which portrays the silhouette of the lumen but cannot distinguish true and false aneurysms. To differentiate true and false aneurysms and to study the morphologic changes of the vessel wall, intravascular ultrasound (IVUS) was performed in patients with angiographic signs of coronary artery aneurysms. We used a 4.8F or 3.5F, 20 MHz IVUS catheter for ultrasound examination. Fourteen patients (12 men and two women ranging in age from 43 to 73 years) with angiographic signs of coronary aneurysm were enrolled. IVUS imaging was optimally obtained in all patients. The vessel area, lumen area, and plaque area of the aneurysm segment and of the proximal and distal segments were determined. IVUS showed that both the proximal and distal reference segments were severely affected by atherosclerotic lesions in all the patients and by calcium deposits in six patients. The percent stenoses were 63.0% +/- 13.7% and 60.9% +/- 17.8% in the proximal and distal reference segments, respectively. In nine patients the walls of the aneurysms showed signs of atherosclerosis. Three angiographically indicated aneurysms were found to be plaque ruptures. Although the lumen and the vessel areas of the aneurysm segments were larger than those of the proximal and distal segments (p < 0.01 and (p < 0.001), no significant differences in plaque area and plaque composition were found between the aneurysm segment and adjacent vessel segments (p > 0.05). In conclusion, IVUS allows detailed characterization of coronary aneurysms. Atherosclerosis seems to play an important role in the formation of acquired coronary aneurysms.

Aneurysm of the left main coronary artery: progression of dilatation with concomitant deterioration of coronary stenoses

A left main aneurysm is a rare angiographic finding. We describe a 59-year-old male with a large aneurysm in the left main coronary artery. The aneurysm had enlarged in comparison to its diameter of 3.5 years previously, together with a progression of severity of his coronary stenoses.

Coronary arterial ectasia: increased prevalence in patients with abdominal aortic aneurysm as compared to occlusive atherosclerotic peripheral vascular disease

Coronary artery ectasia (CAE) is the saccular or fusiform dilatation of a coronary artery. CAE is found in 1.2% to 4.9% of patients at autopsy or during angiographic studies, with a similar prevalence of CAE found in patients with atherosclerotic peripheral vascular disease (PVD). Abdominal aortic aneurysm (AAA) and CAE are similar in pathogenesis and histology. To determine whether CAE occurs more frequently in patients with AAA than in occlusive forms of atherosclerotic PVD, a review of coronary angiograms was performed in patients who underwent cardiac catheterization and vascular reconstruction for AAA or occlusive atherosclerotic PVD of the lower extremities. Of 72 patients with AAA, 15 had CAE (20.8%) compared with only 2 of 69 patients with atherosclerotic PVD (2.9%) (p < 0.003). CAE was predominantly discrete, located in the left coronary system, and associated with significant coronary atherosclerosis. CAE may be more prevalent in patients with AAA resulting from a similar pathogenetic process.

Coronary aneurysms: a case report and review

This case report describes a large coronary aneurysm and poses questions regarding management. The discussion that follows addresses what is known about the natural history of and options for management of coronary aneurysms.

Angioplasty in ulcerative coronary artery disease: acute results and early follow-up

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.

Vasospasm in a coronary artery aneurysm

Coronary artery aneurysms are not believed to have enough intact smooth muscle to generate significant vasoconstriction. A case is presented illustrating vasospasm of a large fusiform aneurysm of a right coronary artery during angioplasty. Pathophysiology of aneurysms is discussed.

Multiple aneurysms of the coronary arteries in a patient with systemic aneurysmal disease

A case of multiple coronary artery aneurysms in a patient with an abdominal aortic aneurysm and bilateral popliteal artery aneurysms is reported. As diagnosis and treatment of coronary artery disease become more aggressive, a higher incidence of detection of coronary artery aneurysms in conjunction with peripheral vascular lesions is likely. The role of coronary sinus cardioplegia in minimizing the risk of embolization from the coronary aneurysms during surgical repair is emphasized.

Coronary artery aneurysm formation following percutaneous transluminal coronary angioplasty: treatment of associated restenosis with repeat percutaneous transluminal coronary angioplasty

Restenosis following coronary angioplasty can usually be treated effectively and safely by repeated angioplasty. However, the presence of a complex lesion morphology may bias the clinician away from angioplasty toward either recommending bypass surgery or continuing medical therapy alone in spite of recurrence of the symptoms which were sufficient indication for the initial angioplasty. One type of complex morphology at the site of the restenosis is due to the presence of a focal, eccentric aneurysmal dilatation similar in appearance to a saccular aneurysm. In two previously reported cases in the literature both were referred to bypass surgery. We report eight additional cases including the use of repeat successful angioplasty in six of the cases in spite of the potential problems posed by the complexity of the restenosed lesion. In addition, this case review suggests that this type of complex lesion morphology with restenosis may be more common when the initial angioplasty was associated with deep arterial injury, as in patients whose initial angioplasty was done in an infarct-related vessel or was associated with evidence of a large dissection.

Serial angiographic findings during the development of a saccular aneurysm of the coronary artery in association with unstable angina

A 60 year old man presented with unstable angina and electrocardiographic features suggestive of disease of the left anterior descending coronary artery. Angiography showed slight proximal narrowing in this artery with reduced density of contrast that suggested an associated thrombus. Repeat angiography after 24 hours of heparin administration showed the development of a small saccular aneurysm. Three weeks later, after a further episode of unstable angina, angiography showed enlargement of the aneurysm. Although there were no further episodes of angina, repeat angiography three months after the initial event showed further slight enlargement of the aneurysm. It is suggested that the episodes of angina at rest were secondary to embolisation of thrombotic or atheromatous material or both.

Acquired coronary arterial aneurysms: an autopsy study of 52 patients

In the past decade most studies of coronary arterial aneurysms have been clinical; few have focused on morphology and etiopathogenesis. The subjects of the present autopsy study were 52 patients, 5 months to 80 years of age, with coronary arterial aneurysms. Patients were divided into two groups: 38 with atherosclerotic coronary aneurysms and 14 with aneurysms secondary to inflammation. Of the 38 patients with atherosclerotic aneurysms, 20 (53 per cent) had histories of ischemic heart disease; the aneurysms were in the right coronary artery in 18 (47 per cent), the left coronary artery in 13 (35 per cent), and in the right and left coronary arteries in seven (18 per cent). Of the four major coronary arteries, the average number of severely narrowed arteries (reduction of more than 75 per cent) in cross-sectional luminal area) was 1.8/patient; aortic aneurysms were present in eight of these patients (24 per cent). Of the 14 patients with coronary aneurysms secondary to inflammation, four had histories of ischemic heart disease; 10 had histories of an influenza-like syndrome. Isolated left coronary arterial aneurysms were seen in six of these patients (43 per cent), while eight (51 per cent) had multiple right and left coronary arterial aneurysms. The average number of severely narrowed coronary arteries in this group was 1.5/patient, and only one patient had an aortic aneurysm. Therefore, patients with atherosclerotic aneurysms are more often symptomatic; they have increased heart weights and equal numbers of coronary arterial aneurysms in the right and left vessels, and the majority (89 per cent) have single aneurysms with thrombi in the lumen. Patients with coronary arterial aneurysms secondary to inflammation are younger; the majority of these patients have a prodromal influenza-like syndrome, a low incidence of ischemic heart disease, and multiple coronary arterial aneurysms.

Coronary ectasia in a homozygous patient with familial hypercholesterolemia

A 23-year-old man with homozygous familial hypercholesterolemia was found to have coronary ectasia by coronary angiography. This case showed generalized xanthomatosis and severe hyper low density lipoproteinemia, and his cultured skin fibroblasts showed LDL receptor activities compatible with the receptor-defective homozygous type of familial hypercholesterolemia. Coronary angiography showed fusiform aneurysmal involvements in the right coronary artery and left circumflex artery, and 50% stenosis in the right coronary artery and left anterior descending artery. Thus, homozygous familial hypercholesterolemia produces coronary ectasia as well as premature coronary stenosis.

Huge left coronary artery aneurysm associated with multiple arterial aneurysms

Natural history of an aneurysm at the bifurcation of the left coronary artery is reported. A gradual increase in its size occurred over an 18-year period until it was a huge and partially thrombosed sac. It was associated with ectasia of the right coronary artery, aneurysms of the left subclavian artery and thoracic aorta, and calcified dilatations of the branches of the celiac trunk.

Fate of nonobstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report

The incidence of coronary aneurysmatic dilatation without coronary stenosis is rare, and the clinical course of such an entity is unknown. We present five adult patients, four men and one woman, with such an anatomic finding. The age range was 44 to 60 years. In four patients the aneurysmatic dilatations involved multiple coronary sites. The clinical course in all five patients was suggestive of coronary insufficiency. Despite no obstructive disease, two of the patients developed transient ischemic ECG changes accompanied by chest pain, and another two patients demonstrated ischemic exercise nuclear ventriculography response. In time, all five patients developed acute myocardial infarction and recatheterization revealed complete occlusion of a previously nonstenosed aneurysmatic vessel. More information is needed in order to guide therapy. However, prevention of thrombus formation and close follow-up is highly recommended.

Coronary arterial aneurysm formation after balloon angioplasty

The mechanism of coronary stenosis dilatation by percutaneous transluminal coronary angioplasty (PTCA) is incompletely understood. Five men who developed coronary arterial aneurysms at the site of PTCA are described. All patients were in New York Heart Association functional class III or IV at the time of PTCA. In 2 patients acute myocardial infarction was evolving and both had acute coronary occlusion. The other 3 patients had angiographic evidence of intimal disruption or acute coronary reocclusion as a result of PTCA, one of whom had undergone emergency coronary artery bypass grafting. Three patients received intracoronary streptokinase during PTCA. One patient was asymptomatic and 4 were symptomatic when the aneurysms were identified between 11 days and 4 months after PTCA. Other than the complex course and anatomy of these patients before and immediately after PTCA, no other features distinguished them from others undergoing this procedure.

Aneurysmal coronary artery disease

To examine the clinical and historical features and the natural history of aneurysmal coronary disease, we reviewed the registry data of the Coronary Artery Surgery Study (CASS). Nine hundred seventy-eight patients, representing 4.9% of the total registry population, were identified as having aneurysmal disease. No significant differences were noted between aneurysmal and nonaneurysmal coronary disease patients when features such as hypertension, diabetes, lipid abnormalities, family history, cigarette consumption, incidence of documented myocardial infarction, presence and severity of angina, and presence of peripheral vascular disease were examined. In addition, no difference in 5-year medical survival was noted between these two groups. These findings suggest that aneurysmal coronary disease does not represent a distinct clinical entity but is, rather, a variant of coronary atherosclerosis.

Circumflex coronary artery aneurysm visualized by real-time cross-sectional echocardiography. A possible sequelae of previously unrecognized coronary arteritis in the adult

Real-time cross-sectional echocardiography disclosed an aneurysm of the circumflex branch of the left coronary artery in an asymptomatic 30-year-old man. Plain chest roentgenogram showed an abnormal silhouette along his left heart border. He also was found to have an abnormal contraction pattern of the posterolateral wall of the left ventricle and a reduced left ventricular ejection fraction. Left ventricular and coronary angiography showed a similar impairment in left ventricular function and occlusion of the circumflex branch of the left coronary artery. Surgery and pathologic examination confirmed the presence of the aneurysm. The echocardiographic characteristics of this lesion and the left ventricular contraction abnormalities suggest the possibility that it resulted from a remote episode of coronary arteritis. Real-time cross-sectional echocardiography, by virtue of its ability to provide visualization of structures along the posterior border of the heart as well as information about regional wall motion, may be of considerable value in localizing and defining lesions occurring in this area.

Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature

Three cases of large multiple coronary aneurysms, situated on both right and left coronary arteries, were seen in three middle-aged adult patients. These patients were hospitalized for myocardial infarction in two cases and for angina pectoris in the third case. On the coronary angiogram, the coronary lesions were quite unusual as there were multiple voluminous aneurysms on both coronary arteries without evidence of atherosclerotic lesions of the remainder of the coronary tree. These lesions did not seem to be congenital or atherosclerotic, and it was postulated that these lesions might have been the sequelae of a mucocutaneous lymph node syndrome although no previous history of this condition could be found in these three patients.

Arteriosclerotic aneurysm of the coronary artery

The findings in a patient with an angiographically proven aneurysm of the coronary artery are described. The case is reviewed in the light of 115 similar cases reported in the literature. The patient had had numerous episodes of variant angina, a feature not previously described in coronary arterial aneurysms, which may be related to embolic showers originating from the aneurysm.

Spontaneous rupture of a coronary artery with false aneurysm formation. Successful surgical repair

A patient with diffuse atherosclerotic coronary arterial disease was demonstrated to have a spontaneous rupture of the proximal right coronary artery, with formation of a false aneurysm. This was recognized at angiographic study, and the patient subsequently underwent a revascularization operation with suture ligation of the aneurysm.

Coronary artery aneurysms: study of the etiology, clinical course and effect on left ventricular function and prognosis

Coronary artery aneurysms were found in 16 men between 37 and 62 years of age, mean 51 years. Aneurysms were of two types: saccular and fusiform. They involved the right coronary artery in 13 (87 per cent), the circumflex artery in eight (50 per cent) and the left anterior descending artery in five (31 per cent). In some patients, more than one vessel was involved. Twelve patients presented with angina pectoris, three with congestive heart failure and one with both. Five were in functional class II, eight were in class III and three were in class IV at the beginning of the study. The electrocardiogram showed evidence of previous myocardial infarction in four patients; four patients had left ventricular hypertrophy, one had left axis deviation, one had left bundle branch block, one had right bundle branch block, two had first degree atrioventricular block and seven had abnormalities in the S-T segment and T wave. Obstructive coronary disease was present in all; the obstruction score was from 1 to 4 in three patients, from 5 to 9 in four patients and from 10 to 14 in the remaining nine. Similar aneurysms were found in the pulmonary artery of one patient and in the abdominal aorta of three patients; in seven of 14 patients with adequate venous angiograms, varicosities of the coronary venous tree were observed. Left ventricular dysfunction and angina pectoris were noted in patients with significant obstructive coronary disease (greater than 70 per cent) and also in patients without obstruction but with coronary aneurysms. Ten patients were treated surgically; nine underwent aortocoronary bypass and one mitral valve replacement. Criteria for bypass was the presence of obstructive disease and medically unresponsive angina pectoris. All but one surgically treated patient showed improvement. The functional class in medically treated patients was unchanged. Fourteen patients were still alive at the completion of the study. The findings of this study suggest that angina pectoris and left ventricular dysfunction can occur with coronary artery aneurysm without coronary artery obstructions. Coronary aneurysms may be a subset of atherosclerosis, and this process may involve other vascular territories. The prognosis in those patients appears to be no worse than in patients with obstructive coronary disease and no aneurysms.