Giant coronary aneurysm in a patient with systemic lupus erythematosus

Giant left anterior descending artery aneurysm in a patient with active systemic lupus erythematosus: a case report

BACKGROUND

Although not common, coronary artery aneurysms (CAAs) can develop to over 8 mm in diameter to become giant CAAs. In the context of systemic lupus erythematosus (SLE), autoantibody- and immune complex-mediated atherosclerosis is believed to be the most prevalent cause of aneurysm.

CASE PRESENTATION

We report the case of a 53-year-old female SLE patient who presented to our hospital with radiating chest pain. Coronary angiography revealed a giant aneurysm in the middle segment of the left anterior descending artery (LAD) and distal subtotal occlusion in the left circumflex artery (LCX). Laboratory testing also identified risk factors such as an abnormal pulmonary enzyme profile, dyslipidemia, and nephritis parameters.To prevent thromboembolism, anticoagulation and antiplatelet therapy were administered. In addition, one stent was implanted at the distal end of the LCX and repeated coronary angiography verified restoration of TIMI grade III flow.The patient was discharged with resolved chest pain. During 6 months of follow-up, the patient is in good health.

CONCLUSIONS

Our case study, together with 16 recent comparable reports, emphasizes the need for coronary aneurysm screening in SLE patients. It is necessary that thromboembolism, anticoagulation and antiplatelet therapy were administered for CAA.

Multiple coronary aneurysms and acute myocardial infarction in a female patient with rhupus: case report and literature review

Coronary artery aneurysms (CAA) are an infrequent cause of coronary artery disease in both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), most occurring as a result of acute coronary syndromes (ACS). Until now, no cases of CAA have been described in a patient with rhupus syndrome (RhS). Differentiating whether CAA stem from primary vasculitis, atherosclerosis, or a combination of both continues to pose a significant challenge. We present the first described clinical case of a 43-year-old patient with RhS and multiple CAA identified by the presentation of an acute myocardial infarction. The presence of multiple cardiovascular risk factors and the absence of inflammatory findings, both in PET-CT and arterial biopsy, favored an atherosclerotic versus a vasculitic etiology of the CAA. At the time of the aneurysms diagnosis, the patient showed no signs of SLE activity and only moderate RA activity, which underscores the importance of screening for silent coronary aneurysms in these patients, even in subjects exhibiting little apparent activity from their underlying disease. This case also exemplifies the severe impact of atherosclerotic burdens on such patients, demanding vigilance and aggressiveness in its prevention, early diagnosis, and treatment. We hypothesize that RhS could engender an even greater risk of presenting CAA than either SLE or RA on their own, which therefore warrants more careful follow-up in these patients.

Giant right coronary artery aneurysm. Case Report

Introduction: Coronary aneurysms are rare and are linked to drug abuse; symptomatology depends on the coronary anatomy. This is a case of acute coronary syndrome associated with a giant right coronary aneurysm.Case description: A 40-year-old male, with history of heroin and crack use since age 20, attended consultation due to dyspnea, stable angina and diaphoresis. An electrocardiogram showed ST segment overlay on the underside and troponin problems. A coronary catheterization was performed, which revealed apparent inconclusive aortato-right atrium fistula. Based on the findings, angiotomography and magnetic resonance imaging were performed, finding a giant right coronary aneurysm. The aneurysm was resected using extracorporeal circuit, femoral cannulation, moderate hypothermia, aortic cross-clamping and cardioplegia, and the right coronary artery was revascularized with the left internal saphenous vein. The patient had a satisfactory postoperative period and was discharged after 7 days.Conclusion: There is an important association between drug use and the development of coronary aneurysms. Aneurysm size makes diagnosis difficult, so complementary studies are necessary to establish a differential diagnosis. An appropriate surgical approach allows for a complete resection of the aneurysm and optimal coronary revascularization.

Histopathology of Giant Coronary Artery Aneurysm Associated with Coronary Artery Fistula

Giant coronary artery aneurysms related to coronary fistula are rare, and the precise mechanisms by which they occur are unknown. We present a case of giant coronary artery aneurysm of the left coronary artery to the pulmonary artery fistula with a lack of internal and (or) external elastic lamina and medial degeneration.

Coronary artery aneurysm combined with other multiple aneurysms at multiple locations: A case report and systematic review

BACKGROUND

Coronary artery aneurysm (CAA) with concomitant aneurysms at multiple sites is quite unusual and rare. The characteristics and the etiology of this phenomenon are unknown.

METHODS

Herein, we present a case with right coronary aneurysm with concomitant abdominal aorta as well as right renal artery aneurysm. A systematic review of the literatures regarding CAA with other coexisting aneurysms at multiple locations was also conducted on Medline and Embase databases.

RESULTS

A total of 76 patients (male gender: 58; age: 37.4 ± 26.5) including the present case were included in the final study. The most common etiology of CAA with multiple aneurysms was Kawasaki (43.3%) and atherosclerotic disease (16.4%). CAA was the most frequently found at the right coronary artery (62.7%), following, left anterior descending (51%), left main (43.1%), and left circumflex (35.3%). The most common concomitant aneurysms were abdominal aorta (52.6%) and iliac artery (50%). In addition, 60.5% of the patients had an involved bilateral peripheral artery.

CONCLUSION

CAA with coexisting systemic aneurysms in multiple sites is quite rare. And it usually involves multiple aneurysms at the coronary and bilateral peripheral arteries simultaneously. Currently, there are no general consensus regarding the clinical characteristics, diagnostic method, and treatment of these cases.

Epidemiology and risk factors of coronary artery aneurysm in Taiwan: a population based case control study

OBJECTIVES

Coronary artery aneurysm (CAA) is usually an asymptomatic and rare disease. There are limited epidemiological data for CAA in Asian populations and in the rest of the world.

DESIGN

A retrospective case control study.

SETTING

A population based, database study from Taiwan's National Health Insurance Research Database, between 2005 and 2011.

PARTICIPANTS

CAA patients identified using International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) code 414.11 with CAA examinations.

OUTCOME MEASURES

The incidence rate and mortality rate of CAA were calculated. We also matched patients with non-CAA patients according to age, gender and index year at a 1:10 ratio to explore the risk factors for CAA using conditional logistic regression.

RESULT

A total of 1397 CAA patients were identified between 2005 and 2011; 41.9% were paediatric patients and 58.1% were adults. The incidence rate and mortality rate of CAA in Taiwan were 0.87 and 0.05 per 10⁵ person-years, respectively. The adjusted odds ratios (aOR) for coronary atherosclerosis, hypertension, dyslipidaemia and diabetes were 7.97, 2.09, 2.48 and 1.51, respectively. Of note, aortic dissection (aOR 6.76), aortic aneurysm (aOR 5.82) and systemic lupus erythematosus (aOR 4.09) were found to be significantly associated with CAA.

CONCLUSION

In Taiwan, CAA patients were distributed across both paediatric and adult populations. Apart from cardiovascular risk factors, aortic diseases and systemic lupus erythematosus need to be investigated further in CAA patients.

A Rare Combination of Giant Right Coronary Artery Aneurysm

Context:

Giant coronary artery aneurysm (CAA) in adults is a rare clinical entity with an estimated incidence of 0.02%. CAA is commonly found in the right coronary artery with significant number of cases associated with fistula formation.

Case Report:

We describe a rare case of an 87 year-old man with large CAA with fistulous drainage into the right ventricle (RV) along with RV free wall vegetation as a cause of chronic weakness and lethargy.

Conclusion:

Giant CAA with fistulous drainage to the RV could present in the form of infective endocarditis. Early detection and surgical treatment would provide a significant benefit to these patients.

Systemic lupus erythematosus coronary vasculitis demonstrated on cardiac computed tomography

Coronary artery aneurysms are an uncommon manifestation of systemic lupus erythematosus (SLE), with only 14 cases reported previously in the literature. Herein, we report a 29-year-old woman with SLE who developed clinical and serologic evidence of an SLE flare and presented with chest pain and elevated serum troponin-T level. Cardiac computed tomography was performed and demonstrated fusiform aneurysmal enlargement of the proximal and middle portions of the coronary arteries and a beaded appearance of the distal coronary arteries. Extensive intercostal artery aneurysms were also noted. Several areas of abnormal myocardial perfusion were also noted. The patient improved after treatment with steroid pulses and cyclophosphamide. This case report is the first description of the appearance of lupus coronary vasculitis on cardiac computed tomography.

Diverse vascular lesions in systemic lupus erythematosus and clinical implications

PURPOSE OF REVIEW

Vascular injury is one of the typical symptoms of systemic lupus erythematosus (SLE), and may play a key role in the choice of treatment strategy and prediction of prognosis. In this review, diverse vascular lesions in SLE and their clinical significance are discussed.

RECENT FINDINGS

The clinical features of vascular disease in SLE differ from organ to organ, and may be extreme with regard to renal vascular lesions. Vascular lesions in SLE may be of inflammatory or thrombotic origin, and immune system dysfunction is considered to be a predominant feature. Numerous lines of evidence suggest that the activation and injury of endothelial cells might play a key role in the pathogenesis.

SUMMARY

Vascular lesions in SLE are mediated by a complex interaction between the immune system and other contributing factors. Different therapies developed for vascular lesions, both immunosuppressive and nonimmunosuppressive, should be selected based on the different clinical and pathological characteristics, and our future understanding of the different mechanisms involved.

Fatal multiple coronary involvements in a young woman with systemic lupus erythematosus

We report a rare case of fulminant congestive heart failure with fatal outcome in a 21-year-old girl with systemic lupus erythematosus (SLE). A young woman was admitted in the intensive care unit for pericardial tamponade associated with disseminated coagulopathy and refractory shock secondary to multiple coronary aneurysms. Post-mortem examination revealed significant multiple coronary lesions with aneurysms of the interventricular and right coronary arteries, responsible of muscular necrosis, thrombosis of the coronary sinus, and significant pericardial infiltration with hemorrhagic fluid. We describe a refractory cardiac failure with extensive coronary artery involvements, which is very uncommon in young patients with SLE: few cases have been previously described in the literature. We report a rare case of fulminant congestive heart failure with fatal outcome in a young woman with SLE related to extensive coronary involvements.

The management of concomitant renal oncocytoma and giant coronary and bilateral common iliac artery aneurysms

We present the rare case of a 66-year-old Caucasian male patient presenting with intermittent left-side abdominal pain. He underwent a kidneys, ureters, and bladder computed tomography scan on which an incidental 45-mm giant aneurysm of the left anterior descending coronary artery was discovered along with 55-mm right-sided and 62-mm left-sided common iliac artery aneurysms and a 100-mm benign renal oncocytoma. He underwent on-pump coronary artery bypass grafting of the left anterior descending, left circumflex and right coronary arteries using internal mammary artery and saphenous vein grafts. He subsequently underwent simultaneous open left nephrectomy and bilateral common iliac aneurysm repair using a bifurcated tube graft. He made a full recovery postoperatively. Giant coronary artery aneurysms are rare. In the pediatric population, they are predominantly secondary to Kawasaki disease. In adults, atheromatous disease is the leading cause. The coexistence of giant coronary artery aneurysms with extracoronary artery aneurysms is extremely unusual. We propose that the identification of giant coronary artery aneurysms necessitates further imaging investigations to identify the presence of extracoronary aneurysms. To our knowledge, this is the first description of such a case in the literature.

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.

Antiendothelial cell antibodies in patients with coronary artery ectasia

BACKGROUND

The mechanisms involved in the pathogenesis of coronary artery ectasia (CAE) have not been elucidated. Circulating antiendothelial cell antibodies (AECA) are often detectable in systemic vasculitis and have been implicated in the pathogenesis of endothelial injury. Their prevalence in CAE is not known.

METHODS AND RESULTS

Out of 475 consecutive patients subjected to coronary angiography, 27 patients were diagnosed with CAE. Thirty patients matched for age, body mass index, sex, and coronary artery disease prevalence, served as controls. Serum AECA of IgG, IgM, and IgA isotypes were detected using a cell-based enzyme-linked immunosorbent assay (ELISA). Antinuclear antibodies (ANA) and antineutrophil cytoplasmic antibodies (ANCA) were detected using indirect immunofluorescence. IgG and IgM anticardiolipin antibodies (aCL) were detected using commercial ELISA. The prevalence of ANA and ANCA was similar in CAE patients and controls (33.3 vs. 43.3%, and 3.3 vs. 7.4%, respectively). There was no significant difference in IgG or IgM aCL reactivity between patients and controls. Both CAE patients and controls were negative for IgG AECA. The frequency of IgM AECA positivity was similar in CAE patients and controls. The prevalence of AECA of the IgA isotype was significantly higher in CAE patients (37.0 vs. 10%, P<0.05).

CONCLUSION

There is increased prevalence of circulating AECA of the IgA isotype in patients with CAE. This provides evidence for a role of autoimmunity in the pathogenesis of certain cases of CAE.