Post Traumatic Pseudoaneurysm of Left Anterior Descending Artery Presenting as Acute Coronary Syndrome

Coronary artery intramural hematoma causing myocardial infarction mimicking pseudoaneurysm or dissection from trauma: A case report

Blunt chest trauma caused ST-segment elevation myocardial infarction. Diagnosis of intramural hematoma (IMH) using computed tomography was confirmed using electrocardiography, cardiac marker tests, and subsequent coronary angiography. After conservative treatment, the hematoma was completely resolved 1 year later. Differentiating IMH from other arterial injuries is critical for appropriate management.

ECG-Gated CCTA in the Assessment of Post-Procedural Complications

INTRODUCTION

The aim of our study was to assess the role of ECG-gated coronary CT angiography (CCTA) in the diagnosis, imaging follow-up, and treatment guidance in post-procedural/surgical interventions in the heart and thoracic aorta (PTCA, TAVI, PMK/ICD placement, CABGs).

MATERIALS AND METHODS

We retrospectively evaluated 294 ECG-gated CCTA studies performed in our center from January 2020 to January 2023. CCTA studies were acquired to detect/exclude possible complications related to the endovascular or surgical procedure.

RESULTS

There were 27 cases (9.2%) of post-procedural complications. Patients enrolled in the study were 18 males and 9 females (male/female ratio: 2), with age ranging from 47 to 86 years (mean age, 68.3 years). Among percutaneous coronary intervention (PCI) complications, coronary intimal dissection with ascending aorta involvement was found to be the most frequent complication after PTCA (22.2%). Vascular wall pseudoaneurysm formation (11.1%) and coronary stent misalignment or displacement (14.8%) were complications less frequently encountered after PTCA. Right atrial or ventricular perforation with associated hemopericardium were the most common complications (18.5%) after pacemaker implantation. Complications encountered after aortic valve interventions were loosening and dislocation of the prosthesis associated with aortic root pseudoaneurysm (7.4%), para-valvular leak (11.1%), and hemopericardium (7.4%). In one patient who underwent transcatheter repair of patent foramen ovale (3.7%), CTTA detected the dislocation of the Amplatzer septal occluder.

CONCLUSIONS

ECG-gated CCTA is a fundamental diagnostic tool for the detection of post-procedural endovascular/surgical complications to enable optimal patient management. Radiologists must be familiar with the use of cardiac synchronization in the course of CT and must be aware of all possible complications that can occur in the context of acute settings or routine follow-up studies.

No Ordinary Coronary: A Case Series of Two Large Coronary Artery Aneuryms Found on Chest X-Ray

BACKGROUND

Post-procedural coronary aneurysms can have high morbidity and mortality. Although found more commonly on ultrasound or computed tomography imaging, if large enough, they may appear on chest x-ray studies.

CASE REPORTS

We present two cases of coronary artery aneurysm visible on chest x-ray study-one originating from a saphenous vein graft and the other a left anterior descending artery pseudoaneurysm 1 week post heart catheterization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important for emergency physicians to recognize abnormal chest x-ray studies and to look for post-procedural complications, such as coronary artery aneurysm. Coronary artery aneurysm can be a potentially life-threatening condition requiring prompt recognition and surgical consultation.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Challenges and strategies in the management of coronary artery aneurysms

Coronary artery aneurysms (CAAs) are infrequent but not rare. Because of the lack of supportive data and a substantial knowledge gap in this field, clinicians are in a dilemma how to manage patients with coronary artery aneurysms. Most often, CAAs are discovered incidentally, while symptomatic patients present with diverse complications of unstable angina, myocardial infarction, arrhythmias, or sudden cardiac death. Therapeutical approaches consist of surgical procedure, percutaneous coronary intervention (PCI), and medical management. Because of the scarcity of randomized trials or large-scale data on symptomatic and asymptomatic patients with coronary artery aneurysms, the management of these patients poses considerable challenges for the cardiologists. This review summarizes the current literature, a proposed algorithm for the management of CAAs is highlighted in the text. In view of the majority of current proposal information based on small series of case reports or observational studies, an individualized therapeutic regimen should be on the basis of the location, expansion by time, morphology, complications, and etiologies of the coronary artery aneurysms, the clinical presentations, and the patient's characteristics.