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

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.

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.

Results of drug-eluting stent in significant restenosis of the hemodialysis access: An initial study

BACKGROUND

This study aimed to report the 12-month results of drug-eluting stent (DES) for the treatment of significant restenosis of the hemodialysis access.

MATERIALS AND METHODS

A total of 14 patients (seven men and seven women; median age 70 years; range of 50-83 years) with significant restenosis of hemodialysis accesses were enrolled from January 2017 to December 2018. A total of 10 arteriovenous graft (AVG) and four arteriovenous fistulae were treated with DES. Study outcomes included primary patency of the target lesion and circuit.

RESULTS

Venous anastomosis of the AVG was the most common target lesion for DES insertion (nine hemodialysis accesses). The range of follow-up time was 12-36 months. Primary patency rates of target lesion before DES (patency for last conventional balloon angioplasty [CBA]) versus target lesion after DES at 6 and 12 months were 29% versus 100% and 7% versus 86% (p < 0.001). Primary patency rates of pre-DES circuit (patency for last CBA) versus post-DES circuit at 6 and 12 months were 29% versus 64% and 7% versus 29%, respectively (p = 0.058).

CONCLUSION

DES might improve the patency rate of target lesion in patients with significant restenosis of the hemodialysis access.

Postangioplasty aneurysm of right coronary artery

BACKGROUND

Coronary artery aneurysms are an uncommon disease whose incidence ranges from 0.3% to 5.3%. The right coronary artery is affected in 40%-70% of cases. Percutaneous coronary angioplasty is among causative factors, in particular with stent implantation.

AIMS

We present a case of large postangioplasty aneurysm of the right coronary artery requiring surgical correction.

MATERIALS & METHODS

A 70-year-old man with history of multiple coronary angioplasty procedures was admitted with diagnosis of aneurysm of the right coronary artery at the site of past DES insertion.

RESULTS

Under cardiopulmonary bypass, the large aneurysm was incised and oversewn with final grafting of the posterior descending artery with in situ right internal mammary artery. The postoperative course was uneventful.

DISCUSSION

The treatment options for coronary artery aneurysms range from medical, percutaneous and surgical approaches.

CONCLUSION

In this case the surgical approach was indicated due to the large aneurysm and the high risk of rupture.

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.

Resection of a large mycotic aneurysm of the left anterior descending coronary artery

A 50-year-old Indigenous woman, on home haemodialysis, was found to have a large mycotic aneurysm of the proximal left anterior descending coronary artery at the site of a previous drug-eluting stent. Blood cultures grew methicillin-sensitive S taphylococcus aureus bacteraemia. She underwent a complex operation involving resection of the mycotic aneurysm, removal of the stent and a coronary artery bypass graft to the distal left anterior descending (LAD) coronary artery using the left internal mammary artery. She had a complicated intensive care unit admission with pericardial tamponade on day 1 postoperatively requiring reopening and removal of clot and type 1 respiratory failure requiring reintubation on day 10 postoperatively. Once extubated, she developed prolonged hyperactive delirium and a significant decline in mobility. Over the course of a 6-week hospital admission, she received extensive multidisciplinary care and was discharged for rehabilitation to a peripheral hospital. She was discharged home after rehabilitation with ongoing follow-up with infectious diseases.

1-Year All-Comers Analysis of the Eluvia Drug-Eluting Stent for Long Femoropopliteal Lesions After Suboptimal Angioplasty

OBJECTIVES

The aim of this study was to assess the performance of the fluoropolymer-based paclitaxel-eluting stent (PES) in long femoropopliteal lesions.

BACKGROUND

The new-generation fluoropolymer-based PES showed promising outcomes in short femoropopliteal lesions. The main feature of the stent is its controlled and sustained paclitaxel release over 12 months. However, the safety and efficacy of this technology in longer femoropopliteal lesions remain unclear.

METHODS

Between March 2016 and March 2017, 62 patients were included in this analysis. Indications for fluoropolymer-based PES deployment were insufficient luminal gain or flow-limiting dissection after plain old balloon angioplasty in a femoropopliteal lesion. Primary patency, freedom from target lesion revascularization, amputation-free survival, and paclitaxel-related adverse events were retrospectively analyzed for up to 1 year of follow-up.

RESULTS

Lesions were de novo in 84% of patients. Mean lesion length was 20 ± 12 cm, and 79% of the lesions (n = 49) were chronic total occlusions. Moderate or severe calcification was present in 42% of the lesions (n = 26). Stent implantation involved the distal superficial femoral artery and the proximal popliteal artery in 76% (n = 47) and 44% (n = 27) of patients, respectively. The Kaplan-Meier estimate of primary patency and freedom from target lesion revascularization was 87%. Amputation-free survival was 100% for patients with claudication (n = 32 [52%]) and 87% in patients with critical limb ischemia (n = 30 [48%]) (hazard ratio: 6.3; 95% confidence interval: 1.25 to 31.54; p = 0.052). Five aneurysm formations of the treated segments (8%) were thought to be attributable to paclitaxel.

CONCLUSIONS

The fluoropolymer-based PES showed promising 1-year clinical and angiographic outcomes in real-world long femoropopliteal lesions. The long-term impact of aneurysm formation remains to be further investigated.

Coronary Artery Aneurysm after Second-Generation Drug-Eluting Stent Implantation

PURPOSE

We evaluated the incidence, predictors, and prognosis of coronary artery aneurysm (CAA) after second-generation drug-eluting stent (DES) implantation.

MATERIALS AND METHODS

A total of 976 consecutive patients (1245 lesions) who underwent follow-up angiography after second-generation DES implantation were analyzed. Incidence and predictors of CAA were assessed, and clinical prognosis was compared with 34 cases of CAA after first-generation DES implantation using previous CAA registry data.

RESULTS

All 10 cases of CAA (0.80% per lesion) in 10 patients (1.02% per patient) were detected at follow up. Compared to lesions without CAA, those with CAA had greater involvement of the proximal segment (90% vs. 51%, p=0.014), a higher proportion of pre-intervention, a Thrombolysis in Myocardial Infarction score of 0 or 1 flow (80% vs. 16%, p<0.001), more chronic total occlusions (40% vs. 10%, p<0.001), and longer implanted stents (41.9±23.2 mm vs. 28.8±14.8 mm, p=0.006). As for CAA morphology, instances of CAA after second-generation DES were predominantly the single fusiform type (90%), whereas instances of CAA after first-generation DES were multiple saccular (47%) and single saccular (35%) types (p<0.001). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA after first-generation DES (15%), and no adverse events were observed in patients with CAA after second-generation DES over a median follow-up duration of 4.3 years (p=0.047, log-rank).

CONCLUSION

Although CAAs after second-generation DES implantation were detected at a similar incidence to that for CAAs after first-generation DES implantation, second-generation DES-related CAAs had different morphologies and more benign clinical outcomes versus first-generation DES-related CAAs.

Non-arrhythmic causes of sudden death: A comprehensive review

Sudden cardiac death (SCD) is a major public health issue in the United States and worldwide. It is estimated to affect between 1 and 1.5 million patients worldwide annually, with the global burden expected to rise due to the concomitant rise in coronary artery disease in the developing world. Although arrhythmic causes of SCD such as ventricular tachycardia and ventricular fibrillation are common and well-studied, non-arrhythmic causes are also important, with diverse etiologies from ischemia-related structural heart disease to non-ischemic heart diseases, non-atherosclerotic coronary pathologies, and inflammatory states. Recent research has also found that risk factors and/or demographics predispose certain individuals to a higher risk of non-arrhythmia-related SCD. This review discusses the epidemiology, mechanisms, etiologies, and management of non-arrhythmic SCD.

Coronary Artery Aneurysm Caused by a Stent Fracture

Coronary stent fracture (SF) is rare as a complication of percutaneous coronary intervention (PCI), and its adverse events are increasingly being recognized with the development in devices of PCI. The major adverse events caused by SFs are in-stent restenosis due to neointimal overgrowth caused by poor drug delivery.^1,2) A coronary artery aneurysm (CAA) is a rare complication of SF, but may lead to lethal events such as acute coronary syndrome or rupture of the CAA further leading to cardiac tamponade.^3-5) However, the management of CAAs is controversial with or without SF.⁶⁾ Herein, we report a case of a CAA caused by an SF and discuss the management of CAA complicated with SF, along with a literature review. We suggest that surgical treatment should be considered the higher-priority strategy in the cases of CAA with SF as compared to CAA without SF.

Three-vessel coronary artery aneurysmal disease complicated by multivessel thrombosis and cardiogenic shock: the saving role of intracoronary thrombolysis

The benefit of intracoronary thrombolytics in ST-elevation myocardial infarction (STEMI) is not well established. Mainstays of STEMI management include intravenous thrombolytics, percutaneous coronary interventions and surgical revascularisation. However, in cases of STEMI secondary to coronary artery aneurysmal disease (CAAD), standard treatment options may not be suitable due to high thrombus burden, perioperative risk and factors unique to each patient. Thus, STEMI management in CAAD can represent a therapeutically challenging clinical scenario. Here, we describe a patient with severe three-vessel CAAD complicated by multivessel thrombosis and cardiogenic shock for whom traditional management options including placement of haemodynamic support devices were not feasible. As an alternative measure, the patient was treated with intracoronary thrombolysis with remarkable clinical stabilisation and angiographic resolution of thrombosis. He remains clinically stable several years later without recurrent events. This case serves to demonstrate the potential lifesaving benefit of intracoronary thrombolysis in complicated multivessel CAAD.

Effectiveness of Bare Metal Stent Implantation for the Treatment of Coronary Artery Aneurysm: A Multimodality Imaging Evaluation

Coronary artery aneurysm (CAA) after sirolimus-eluting stent (SES) implantation is one of the most troublesome problems associated with first-generation drug-eluting stents. However, the natural course and standard therapy of CAA has been unknown. A 49-year-old man underwent SES implantation for the left anterior descending artery. Follow-up coronary angiography (CAG) revealed CAA in the SES. We performed bare metal stent (BMS) implantation for treatment of CAA. Ten months after the BMS implantation, the size of the CAA had diminished, and a very thin layer of endothelium on the BMS was observed by optical coherence tomography. CAG assessment revealed that the blood stream of the CAA had been obstructed. We herein report a case of CAA after SES implantation with eight years of follow-up and the findings of a multimodality imaging evaluation.

Clinical outcomes of patients with coronary artery aneurysm after the first generation drug-eluting stent implantation

OBJECTIVES

We sought to investigate the long-term clinical outcomes of patients with coronary artery aneurysm (CAA) after drug-eluting stent (DES) implantation, compared with patients without CAA.

BACKGROUND

CAA developed after DES implantation is a rare but associated with poor clinical outcome.

METHODS

We retrospectively compared 78 patients with CAA after DES implantation with 269 patients without CAA who underwent DES implantation for complex lesions (controls). The primary endpoint was defined as major adverse cardiac events (MACE), the composite of all-cause death, nonfatal myocardial infarction (MI), and target lesion revascularization (TLR).

RESULTS

Morphologically, CAAs were saccular (32%), fusiform (13%), or microform (55%). The stent types involved were Cypher (n = 56, 71.8%) and Taxus (n = 22, 28.2%). During a median follow-up period of 1164 days, the incidence of MACE was significantly higher in the CAA group (26.9 vs. 2.2%, P < 0.001); the difference was driven mainly by nonfatal MI (11.5 vs. 0%, P < 0.001) and TLR (20.5 vs. 1.9%, P < 0.001). The incidence of stent thrombosis was higher in the CAA group (12.8 vs. 0.74%, P < 0.001), irrespective of the maintenance of dual antiplatelet therapy. In the CAA group, Cox regression analysis showed significantly higher hazard ratios of CAA for MACE during the follow-up period. Further analyses after propensity-score matching of 65 pairs also showed similar results.

CONCLUSIONS

The incidence of MACE was higher in patients with CAA compared with patients without CAA after DES implantation. This difference was driven by TLR and nonfatal MI and widened over time.

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.

Coronary artery fistula with giant aneurysm and coronary stenosis treated by transcatheter embolization and stent

Coronary artery fistula (CAF) with giant aneurysm and accompanied by coronary artery stenosis is a very rare disease. Herein, we report a case of a 76-year-old woman having a complex coronary-to-pulmonary artery fistula associated with a giant aneurysm and accompanied by coronary artery stenosis. The patient was successfully treated using transcatheter coil embolization and coronary stent implantation. Eight years later, we performed a follow-up coronary angiogram, which revealed the CAF and the aneurysm were completely occluded and previous stent patency.

Predictors of coronary artery aneurysm after stent implantation in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

The clinical and angiographic predictors of coronary artery aneurysm (CAA) formation in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are not clear. This study aims to assess the predictors of CAA formation after primary PCI. 3,428 patients who underwent PCI for STEMI were enrolled. The average period of follow-up was mean 48 months (range 35-56 months) after PCI. During this time, 1,304 patients were underwent follow-up coronary angiography. CAA was detected in 21 patients (1.6 %). CAA occurred at the segment of stent implantation in all patients. The clinical and angiographic data were compared between patients with CAA group (n = 21) and without CAA group (n = 1,283). Patients who developed CAA had longer reperfusion time, higher high-sensitiviy C-reactive protein (hs-CRP) levels and neutrophil to lymphocyte ratio than those who had without CAA. Angiographically, CAA developed proximally located lesions and lesion length was significantly greater in patients with CAA than without CAA. Statin and beta-blocker discontinuation were found higher in stent-associated CAA. Every 1 mg/l increase in hs-CRP and implantation of drug eluting stent (DES) were independent predictor of CAA formation after STEMI. Baseline elevated inflammation status and DES implantation in the setting of STEMI may predict the CAA formation.

No indication for an unexpected high rate of coronary artery aneurysms after angioplasty with drug-coated balloons

AIMS

Coronary artery aneurysms (CAA) are a rare complication after percutaneous coronary intervention (PCI) and are reported with an incidence of 0.6% to 3.9%. While in recent years the use of paclitaxel drug-coated balloons (DCB) has increased, so far no CAA formation after DCB intervention has been reported.

METHODS AND RESULTS

During the years 2010 and 2011 we used DCBs in 704 PCIs. Follow-up angiography was scheduled at four months in all patients and has so far been achieved in 380 PCIs. In three patients we found development of a CAA at the former PCI site within four months of observation. Aneurysm length varied between 8.4 mm and 13 mm and lumina increased 58% to 131%. Retrospectively all patients with CAA development showed small intimal dissection partially with tiny persisting contrast bands parallel to the lumen according to type B and type C of the NHLBI classification after PCI.

CONCLUSIONS

CAA formation after DCB intervention was found in three out of 380 PCIs with DCB, consistent with an incidence of 0.8%. Thus, PCI with DCB does not cause an unexpectedly high rate of coronary artery aneurysms.

A case of giant coronary artery aneurysm with fistulous connection to the pulmonary artery: a case report and review of the literature

Giant coronary artery aneurysm is a rare condition with a reported prevalence of 0.02%. Herein, we report the case of a 79-year-old woman with a giant coronary aneurysm arising from a branch of the left anterior descending coronary artery that had a fistulous connection to the pulmonary artery. The aneurysm was removed and inflow and outflow arteries were closed surgically. Histology showed prominent mucinous degeneration and infiltration of inflammatory cells in the medial layer. After successful surgery, the patient was discharged uneventfully.

Acute myocardial infarction late following stent implantation: Incidence, mechanisms and clinical presentation

Acute myocardial infarction (AMI) can occur late following stent implantation with an incidence up to >6% at 3-4 years, with no difference between DES and BMS. AMI can originate either from the stented site or from disease progression at nonstented sites. Restenosis, against previous thoughts, can lead to AMI. Stent thrombosis occurs with similar overall frequency following DES and BMS implantations, although a higher very late stent thrombosis with DES has been observed. Dissimilar mechanisms between BMS and DES thrombosis are very likely, with impaired neointimal healing being the rule for DES but the exemption for BMS. The use of invasive imaging techniques is useful in elucidating the involved mechanism. Disease progression is a particularly important cause of AMI late post stenting. The angiographic study depicted stent failure and disease progression equally implicated in the AMI late post stenting. When the AMI underlying mechanism is stent thrombosis, it usually occurs earlier and more frequently presented as STEMI compared to the other causes of AMI. The AMI caused by restenosis is more often presented as nonSTEMI, while disease progression leads to AMI later than the other causes. Further research should address equally not only the stent related inadequacies but also disease progression as causes of the future AMI. Angiographic follow-up and intracoronary imaging seem the most appropriate methods to define the exact pathophysiologic mechanism responsible for the AMI post stenting.