A case of early development of giant coronary artery aneurysms after drug-eluting stents implantation: An unpredictable menace

Long-Term Outcomes of Conservative Versus Invasive Approach of Coronary Aneurysm

Introduction

Up to date, the management of coronary artery aneurysm (CAA) is not well defined and depends on local heart team decision. Data reported in literature are scarce and controversial. We aim to compare the long-term outcomes of different therapeutic strategies of CAA (medical vs percutaneous coronary intervention (PCI) vs coronary artery bypass graft(CABG)).

Materials and Methods

A retrospective cohort study was conducted on 100 consecutive patients who underwent coronary angiography at Toulouse University Hospital, Toulouse France and fulfilled the diagnostic criteria of CAA. Coronary angiograms were reviewed, and all necessary data were collected. CAA was defined by a coronary dilation exceedingly at least 50% of reference coronary diameter.

Results

We identified 100 patients with CAA with a mean age of 67.9 ± 12 years. The left anterior descending coronary artery was most affected (36%). CAA is associated with significant coronary artery disease in 78% of cases. The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) was 13% during a median follow-up period of 46.2 ± 24 months. A 53% of patients underwent PCI or CABG. The rate of MACCE was lower in CABG group (9.1%) compared to PCI (14.3%) and medical (12.8%) groups, but without reaching statistically significant level. Longitudinal aneurysm diameter was positively linked to MACCE [OR = 1.109, 95% CI (1.014-1.214), p = 0.024]. No benefits have been attributed to anticoagulant regimen over antiplatelet therapy.

Conclusions

In our retrospective observational study, there seems to be no significant differences in MACCE-free survival between all groups (Medical vs PCI vs CABG). Larger longitudinal aneurysm diameter was identified as a predictor of poor prognosis during follow-up.

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.

Very Early Coronary Artery Aneurysm After Primary Percutaneous Coronary Intervention in Patient With HIV and Thrombophilia

The incidence of coronary artery aneurysms ranges from 0.2% to 10.5%. Aneurysms have been described after percutaneous coronary interventions (PCIs) and hypersensitivity to polymers, nickel, cobalt, inflammatory reaction rich in eosinophils, drug released by the stent, fracture and malapposition of the stent, stent endothelialization delay, high pressures used in the procedures, oversizing of balloons and stents, unhealed dissections, atheroablative techniques, and trauma of the arterial wall are related to appearance of coronary artery aneurysms. In this case report, we described a patient with human immunodeficiency virus and thrombophilia who underwent primary PCI and at the end of the procedure had thrombi in the coronary artery. It was decided by triple therapy and new angiographic study 2 days later. This new angiography revealed thrombi resolution but the appearance of an aneurysm in the middle portion of the drug-eluting stent. The anticoagulant was stopped and we performed watchful waiting strategy with new serial angiograms that revealed progressive reduction and disappearance of the aneurysm. Subsequently triple therapy with warfarin, aspirin and clopidogrel was restarted and the patient progressed asymptomatic and performed his daily activities normally. At 6 months of clinical follow-up, we advised the patient to suspend aspirin and to continue secondary prevention of cardiovascular events.