Coronary artery aneurysm formation after drug-eluting stent implantation

Aneurysmal Degeneration After Paclitaxel-Eluting Balloon Angioplasty

Aneurysmal degeneration after peripheral angioplasty is a potentially serious complication. In this case, the patient underwent repeated angioplasty of a prior vein bypass graft utilizing a paclitaxel-coated balloon. He subsequently developed a progressive aneurysmal degeneration, threatening his bypass, which ultimately required an urgent exclusion with a covered stent. This case represents a rare complication of peripheral bypass graft related to percutaneous intervention as well as paclitaxel-coated devices and warns other practitioners of the increased scrutiny and caution one should exercise in the use of such interventions.

Proximal Left Main Coronary Artery Aneurysm Presenting as ST-Elevation Myocardial Infarction Treated by Stenting

Coronary artery aneurysm (CAA) is a rare cardiac anomaly with a reported incidence of 0.3-4.9% of patients who undergo coronary angiography. The term is used when the coronary artery diameter exceeds more than 50% or 1.5 times the reference diameter. It can be congenital or acquired. The commonest acquired cause in an adult is atherosclerosis and in a child is Kawasaki's disease. The commonest culprit vessel is the Right Coronary Artery (RCA), followed by Left Circumflex (LCx) and Left Anterior Descending (LAD). Left main coronary aneurysms are extremely rare in clinical practice. Coronary angiography is the gold standard procedure, both for diagnosis and treatment. We report a 49-year-old male who presented with anterior wall ST-Elevation Myocardial Infarction (STEMI). The initial angiography showed LAD stent thrombosis, but when the second angiography was done, there was spontaneous recanalization of the LAD. Coronary angiography was performed at our hospital, which revealed a long left main coronary artery aneurysm measuring 9.8 mm-maximum diameter. This was treated with a size 5 × 24 mm Begraft coronary stent.

Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results

BACKGROUND

Coronary aneurysms (1.5 times dilation the reference-vessel) are uncommon and have been diagnosed with increasing frequency with coronary angiography. The incidence varies from 1.5% to 5%. Reported complications are multiple: thrombosis, distal embolization, rupture and vasospasm, causing ischemia, heart failure or arrhythmias. However, the natural history and prognosis remains obscure. We aimed to describe the characteristics of acute patients with coronary aneurysms.

METHODS

Prospective coronariography registry of patients with the diagnosis of coronary aneurysm between 2002 and 2013. Among 51,555 consecutive coronary angiograms, 414 patients with aneurysms were reported, of which 256 were considered acute (82% NSTE-ACS).

RESULTS

Predominantly male (80%, mean age 65.5years), cardiovascular risk factors were common (hypertension 65%, dyslipidemia 65%, obesity 25%, diabetes mellitus 28.5%, and smokers 67%). With frequent coronary stenoses (94%), mostly with one aneurysm (80%), it was observed more frequently in the anterior descending artery. After a median follow-up of 52months, 53 died (14 cardiac causes) and 42% presented a cardiovascular event. Complications from the aneurysm were found in 4. The duration of dual antiplatelet therapy, LVEF, age and peripheral vascular disease highlighted in the multivariate analysis of death.

CONCLUSION

The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low. Patients who present them also have a large burden of atherosclerotic risk factors. In the long-term, the probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself. A more intense and prolonged antithrombotic treatment may result in lower mortality rates.

Rationale and design of a multicenter, international and collaborative Coronary Artery Aneurysm Registry (CAAR)

Coronary artery aneurysm is defined as a coronary dilation that exceeds the diameter of adjacent segments or the diameter of the patient's largest normal coronary vessel by 1.5×. It is an uncommon disease that has been diagnosed with increasing frequency since the widespread appearance of coronary angiography. The published incidence varies from 1.5% to 5%, suggesting male dominance and a predilection for the right coronary artery. Although several causes have been described, atherosclerosis accounts for ≥50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture, and vasospasm, causing ischemia, heart failure, or arrhythmias. The natural history and prognosis remain unknown, as definitive data are scarce. Controversies persist regarding the use of medical management (antithrombotic therapy) or interventional/surgical procedures. Only some case reports or small case series are available about this condition. The Coronary Artery Aneurysm Registry (CAAR; http://www.ClinicalTrials.gov NCT02563626) is a multicenter international ambispective registry that aims to provide insights on anatomic, epidemiologic, and clinical aspects of this substantially unknown entity. In addition, the registry will assess management strategies (conservative, interventional, or surgical) and their short- and long-term results in a large cohort of patients.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov. Unique identifier: NCT02563626.

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.