Polytetrafluoroethylene Stent Deployment for a Left Anterior Descending Coronary Aneurysm Complicated by Late Acute Anterior Myocardial Infarction

Resection of Giant Coronary Artery Aneurysms in a Takayasu's Arteritis Patient

Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies

We describe a rare case of surgical repair of a coronary artery aneurysm with arteriosclerotic changes accompanied by coronary arteriovenous fistula (CAVF) after 26 years of conservative therapy. A 71-year-old woman, diagnosed with CAVF 26 years previously, was admitted to our hospital for general fatigue and dyspnea on exertion. Physical examinations revealed that the CAVF originated from the distal portion of the left circumflex artery (LCX), draining into the coronary sinus (CS); it affected the coronary artery aneurysm with arteriosclerotic changes and was calcified from the left coronary main trunk to the distal portion of the LCX. Treatment without resection of the calcified coronary aneurysm was suggested because of fear of excessive bleeding. The CAVF was closed directly from inside the dilated coronary sinus under cardiopulmonary bypass. The dilated ostium of the left coronary artery was closed using a Xenomedica patch. Coronary artery bypass grafting was performed in the left anterior descending artery (LAD) and posterolateral branch (PL) of the LCX using saphenous vein grafts. Postoperatively, the coronary aneurysm was spontaneously thrombosed for low blood flow. The bleeding might have been uncontrolled if the arteriosclerotic and calcified coronary aneurysm had been incised. Therefore, we successfully thrombosed the calcified coronary aneurysm without resection, after reducing the systemic blood flow to the coronary aneurysm and sustaining the coronary blood flow, performed with CABG.

Giant Aneurysm of the Left Atrial Branch of the Left Circumflex Artery With Fistula

Behcet's disease (BD) is a multiorgan vasculitis of unknown origin, with characteristic skin lesions, recurrent uveitis and neurological manifestations [1–3]. Here we present a case of diffuse coronary artery aneurysms involving three major vessels and its appropriate medical treatment. A 45-year-old man visited our cardiology outpatient clinic with a 2-month history of progressive exertional chest pain (Canadian Cardiovascular Society Class III). The patient had a history of BD, which had been diagnosed 15 years ago, and he was not routinely followed up in our rheumatology clinic due to social reasons. He had no cardiac risk factor. On physical examination he was afebrile, pulse rate was 85 per minute and blood pressure was 130/80 mm Hg. The electrocardiogram revealed normal sinus rhythm. Laboratory tests showed normal high-sensitivity C-reactive protein and negative troponin-T level. Transthoracic echocardiography revealed no abnormality. Exercise stress test showed ST segment depression in leads I, aVL and V4–6, and a coronary angiogram was performed. It demonstrated diffuse fusiform aneurysms located on the left anterior descending (LAD), circumflex (Cx) and right coronary (RCA) arteries with extensive coronary slow flow (Figure 1 A–C). Maximal coronary aneurysm diameter was measured as 6.4 mm for the LAD, 6.8 mm for the Cx and 8.3 mm for the RCA in coronary computed tomography (CT) angiography (Figure 1 D). The patient was treated with anti-ischemic agents, including acetylsalicylic acid, a β-blocker, a statin, an ACE inhibitor and oral nitrates. Thereafter, rheumatology consultation was requested. Intravenous cyclophosphamide 1 g/month and methylprednisolone 1 mg/kg/day (with gradual dose tapering) were initiated as the immunosuppressive (IS) treatment. During the hospital course the patient did not complain of any chest pain, and he was discharged with the same anti-ischemic and IS treatment. One month after discharge, his functional class had decreased to CCS Class I–II. As the patient's symptoms regressed with proper medical treatment, surgical or endovascular interventions were not considered. Three months after discharge, coronary CT angiography revealed no increase in the size of each aneurysm. The patient has been in the regular outpatient clinic follow-up for 1 year, without any increase in his symptoms. Figure 1 Diffuse coronary artery aneurysms involving the left anterior descending, circumflex (A, B) and right coronary artery (C). Computed tomography angiography confirmed three-vessel involvement (D) Behcet's disease is a chronic autoimmune vasculitis that may cause single or multiple coronary aneurysms. Patients may be asymptomatic or present with stable angina or acute coronary syndrome, irrespective of the involved vessels [1, 2, 4]. Since no atherosclerotic coronary stenosis or thrombus formation was detected, relative ischemia due to coronary slow flow was the probable cause of exertional angina in our case. Current practice for the management of coronary artery aneurysms in BD is based on a limited number of case reports. For asymptomatic patients, observation may be considered. Acute or pending rupture, enlarging aneurysms, and severe recurrent ischemia unresponsive to medical treatment, however, necessitate surgical procedures such as aneurysm resection, aneurysm ligation and coronary artery bypass grafting. Percutaneous stenting has been reported but has also been associated with a high risk of thrombosis and pseudoaneurysm formation [3]. In the literature, treatment approaches have not differed between single and multiple coronary aneurysms. In only 2 patients with BD previously reported, the diagnosis was stable angina pectoris, and surgical or endovascular interventions were not performed in either [1, 2]. However, this case highlights the importance of a conservative approach with optimal anti-ischemic and IS therapy in extensive aneurysmatic involvement of coronary arteries due to BD.

Aortocoronary Saphenous Vein Graft Aneurysm: Diagnosis Using Color Doppler and Contrast Transesophageal Echocardiography

Background and Aims: Coronary artery Ectasia is a relatively uncommon problem encountered during coronary angiography with the prevalence ranging from 1.2% to 4.9%. Coronary artery Ectasia and aneurysm both denote an arterial segment the dimension of which is larger than normal arterial segment, both have diameter greater than 1.5 times of normal. The length of dilate segment is greater than its width in Ectasia while less in aneurysm. There is an overlap between risk factors of coronary artery Ectasia and atherosclerosis. The clinical relevance in general, and the appropriate medical management of coronary artery Ectasia specifically, is ill defined, as no randomised prospective studies exists. The study was conducted with an aim to estimate the prevalence of coronary artery Ectasia and aneurysm as well as to study the angiographic characteristics of coronary artery Ectasia and aneurysm undergoing in adult patients’ coronary angiography in tertiary cardiac centre of Nepal. Methods: A retrospective study was conducted in Shahid Gangalal national heart centre, Nepal analysing the angiographic records from cardiac catheterization lab. A total of 447 patients who underwent coronary angiography and meet the inclusion criteria from July, 2019 to December, 2019 were included in the study. Any angiographic evidence of coronary Ectasia and aneurysm, coronary artery involved and it’s extent were analysed and recorded in the proforma. In addition, any associated evidence of coronary artery disease was analysed and recorded in the proforma. Results: The findings of our study revealed the overall prevalence of coronary artery Ectasia (CAE) and Coronary artery Aneurysm as 2.6%. Coronary ectasia was most prevalent in left anterior descending (LAD) artery (83.3%), followed by RCA and left main in 66.7% and 16.7% respectively. In contrast, Coronary aneurysm was mostly seen in RCA (66.7%) followed by LCX (33.3%). In addition, the study also showed the frequency of localised Ectasia as 50 % and the association of significant coronary artery disease with coronary artery Ectasia in 66.67%. Conclusion: CAE and aneurysm are rare phenomenon encountered in routine coronary angiography, with LAD and RCA being most commonly involved in CAE and coronary aneurysm respectively. CAE and aneurysm have significant association with the coronary artery disease.

A 52-year-old female presented with an acute coronary syndrome, anterior T wave inversions, and elevated cardiac markers. After cardiac catheterization, a critical mid-left anterior descending artery (LAD) stenosis involving the origin of the second diagonal branch and a critical mid-right stenosis were observed. It was felt that the “culprit” vessel was the LAD, and a successful angioplasty was performed with a drug-eluting stent (DES), Cypher (Cordis), placed in the LAD and the diagonal branch dilated with a balloon. The right coronary artery (RCA) was treated with a drug-eluting stent 3 days later (Figure 1 …

The etiology of coronary artery aneurysms is unknown. Coronary atherosclerosis is considered to be the main etiology. This case reports a patient with a large coronary aneurysm of the right coronary artery. A 65-year-old woman was hospitalized with intermittent chest pain and underwent coronary angiography and echocardiography which showed a large coronary aneurysm of the right coronary artery. The patient recovered well after ligation of coronary artery aneurysms with additional coronary artery bypass grafting. The etiology of coronary aneurysms is unknown, which is relatively rare and mostly secondary. Majority of coronary artery aneurysms are located in the right coronary artery. There is currently no standard treatment. Surgical treatment of coronary artery aneurysms may be considered as a safe treatment option. The standard surgical treatment for coronary artery aneurysms is unclear. For symptomatic large coronary aneurysms, ligation of coronary artery aneurysms with additional coronary artery bypass grafting can achieve good results.

Kawasaki disease (KD) is an acute systemic inflammatory illness that occurs predominately in children <5 years of age. The reported incidence varies widely depending on the ethnicity of the population and the method of case ascertainment. Recent reports would suggest the annual incidence is ≈20 to 25 per 100 000 children <5 years of age in North America, with the highest reported incidence of 188 being in Japan, where the disease was first described in 1967.1 The illness is self-limited and of unknown cause, but is complicated by a systemic vasculitis with a predilection for small- to medium-sized arteries, particularly the coronary arteries. The majority of patients will have either transient coronary artery dilation or no coronary artery luminal changes as noted on echocardiography. Long-term prognosis for these patients is considered to be excellent. Coronary artery aneurysms occur in 25% of patients, but the prevalence is reduced to ≈4% for patients treated with intravenous immunoglobulin infusion within 10 days of illness onset. Aneurysms are associated with an intense inflammatory cell infiltrate, destruction of the internal elastic lamina, and smooth muscle cell death. Coronary artery involvement is usually maximal within 6 to 8 weeks after the acute episode. Regression of aneurysms can occur primarily through myointimal proliferation, although the arterial structure and function remains abnormal,2 and there is an important ongoing risk of stenoses and occlusions.3 Long-term cardiology assessment and management is required, and some of these patients may require revascularization procedures or, rarely, cardiac transplantation. KD has become the most prevalent acquired cardiac disease in children in developed countries. Article see p 60 Although coronary artery complications are the predominant cause of morbidity and mortality, other cardiovascular abnormalities can occur. Valvulitis is a less prevalent complication, and there have been case reports of important long-term aortic and …

Coronary artery aneurysms (CAAs) due to an immunoglobulin G4 (IgG4)-related disease (IgG4-RD) are relatively rare, and there is no consensus on the choice of treatment method. In the present study, we report the results of the surgical treatment for multiple giant CAAs caused by IgG4-RD. A 71-year-old man was diagnosed with severe aortic regurgitation and CAAs. A blood test showed high IgG4 levels, and computed tomography revealed four giant coronary artery aneurysms: two in the right coronary artery (RCA) (proximal RCA and posterior descending artery (PDA)), one in the left anterior descending (LAD), and one in the diagonal branch (Dx). We planned aortic valve replacement, coronary aneurysm resection, and coronary artery bypass grafting (CABG). After finishing aortic valve replacement, the CAAs in proximal RCA, LAD, and Dx were resected. The proximal and distal tracts of the aneurysm were closed with a pericardial bovine patch and ligation. However, since the distal PDA was too calcified to be anastomosed, and the PDA aneurysm was smaller than the others, it was decided to leave the PDA aneurysm. The anastomoses of SVG-RCA and Dx, as well as the left internal thoracic artery to LAD, were performed. Histopathological examination of the aneurysm wall showed a high IgG4-positive cell/IgG-positive cell ratio, and a diagnosis of IgG4-RD was made. In the treatment of CAAs due to IgG4-RD, it is essential to select a procedure that takes into account the size, location, and nature of the aneurysm, and comorbidities. To ensure resection of the aneurysm and blockade of blood flow, closure of the inflow and outflow tracts with a pericardial bovine patch and CABG are effective.

Reperfusion therapy via percutaneous coronary intervention (PCI) as the preferred method of treatment for an acute ST-segment–elevation myocardial infarction (STEMI) requires the use of potent antiplatelet agents (eg, aspirin, P2Y12 inhibitors, and GPIIb/IIIa antagonists) and anticoagulant therapies, including heparin or bivalirudin,1 both of which have potential risk of bleeding. An increased bleeding risk in some patients with STEMI makes the use of antiplatelet/anticoagulant agents a relative or absolute contraindication to PCI. Acute gastrointestinal bleed (GIB) in the acute coronary syndrome setting is a particularly vexing situation requiring the balancing of risk/benefit for each condition and a resultant high-risk decision for the treatment of either condition. Clinically significant GIB may present concomitantly in an estimated 1.3% of cases of acute coronary syndrome, based on the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.2 Guidance concerning optimal management and ensuing strategies in patients with STEMI and contraindications to antiplatelet/antithrombotic agents, specifically with respect to patients who present with parallel and active GIB from literature is scant at best. In this report, we discuss the challenges of managing competing treatment strategies in a patient who presents with concurrent STEMI and acute active GIB. ### Case Presentation A 68-year-old woman presented to the emergency room with severe nausea and vomiting, accompanied by extreme fatigue, dizziness, and light headedness. The symptoms began 7 hours earlier and had been gradually increasing in severity. Vomitus was nonbilious, nonbloody, without coffee ground appearance. She denied chest pain or pressure, palpitations, orthopnea, and reported only mild dyspnea. Two weeks before presentation, the patient described having melena. Her primary care physician documented hemoglobin of 5.1 g/dL. However, the patient refused a blood transfusion and preferred therapy with only iron infusion. An esophagogastroduodenoscopy revealed no abnormalities. Colonoscopic imaging was inconclusive because of inadequate gastrointestinal preparation. In 2011, the patient had PCI …

Patient: Male, 64-year-oldFinal Diagnosis: Huge coronary aneurysmSymptoms: Chest discomfort • dyspneaMedication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg dailyClinical Procedure: Coronary artery bypass graft surgerySpecialty: Cardiac Surgery • CardiologyObjective:Rare diseaseBackground:Giant coronary artery aneurysm (GCAA) is a rare disease, with an incidence of 0.02% in the general population. GCAA is defined as when the diameter of the coronary artery is more than 4 times the adjacent part or more than 8 mm. There are several causes of GCAA, with atherosclerosis being the most common. Patients with giant coronary artery aneurysms can be asymptomatic or develop chest pain, dyspnea, and palpitations. Complications of GCCA include myocardial infarction, thrombosis, and sudden death, so early treatment is necessary to prevent mortality. There is no standard surgical approach for a giant coronary artery aneurysm.Case Report:A 64-year-old man with hypertension, opium addiction, morbid obesity (body weight 151 kg and BMI 46), and benign prostate hyperplasia presented with a giant coronary aneurysm in coronary angiography. The patient underwent cardiac surgery, and a 42-mm coronary aneurysm was detected. The aneurysm had many orifices that opened to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. Aneurysmectomy and coronary artery bypass graft were successfully performed.Conclusions:Giant coronary artery aneurysms are rare. Patients with giant coronary artery aneurysms may experience sudden death due to myocardial infarction and other cardiovascular complications due to ischemia. Because it is rare, there is no standard surgical approach for a giant coronary artery aneurysm. Further studies need to focus on standardized surgical management of patients with giant coronary artery aneurysms.

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Multiple coronary and cerebral aneurysms in a patient with chronic thromboangiitis