Coronary artery aneurysm is a rare disorder, which occurs in 0.3%–4.9% of patients undergoing coronary angiography. Atherosclerosis accounts for >90% of coronary artery aneurysms in adults, whereas Kawasaki disease is responsible for most cases in children. Recently, with the advent of implantation of drug-eluting stents, there are increasing reports suggesting stents causing coronary aneurysms, months or years after the procedure. The pathophysiology of coronary artery aneurysm is not completely understood but is thought to be similar to that for aneurysms of larger vessels, with the destruction of arterial media, thinning of the arterial wall, increased wall stress, and progressive dilatation of the coronary artery segment.Coronary angiography remains the gold standard tool, providing information about the size, shape, and location and is also useful for planning the strategy of surgical resection. The natural history and prognosis remain unclear.Despite the important anatomical abnormality of the coronary artery, the treatment options of coronary artery aneuryms are still poorly defined and present a therapeutic challenge.We describe four cases, which were managed differently followed by a review of the current literature and propose some treatment strategies.
Background The recently introduced intravascular lithotripsy (IVL) appears promising and relatively safer than conventional approaches when dealing with calcified lesions. Although there are published reports on this novel technology, data from the real world are limited. In this study, we aim to report on the experience of IVL from a real‐world population derived from six European centers that undertake high‐volume complex coronary interventions. Methods and results We enrolled all patients treated with IVL between November 2018 and February 2020 at six centers. Procedural success and complications were assessed along with clinical outcomes, which included: cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR), and major adverse cardiac event (MACE) (composite of cardiac death, TVMI, and TLR). Hundred and ninety patients (200 lesions) with a mean age of 72 years were treated using IVL. Diabetes and chronic kidney disease were present in 50% (n = 95) and 16% (n = 30) of cases, respectively. Acute‐coronary syndromes accounted for 91 (48%) of the cases. Most were de‐novo lesions (77%; n = 154). Upfront use of IVL occurred in 26% of cases, while the rest were bail‐out procedures due to inadequate predilatation with conventional balloons. Adjuvant rotational atherectomy was needed in 17% of cases. Procedural success was achieved in 99% of cases with a complication rate of 3%. During the median follow‐up of 222 days, there was two cardiac deaths (1%), one case of TVMI (0.5%), 3 TLR (1.5%) taking the MACE rate to 2.6%. Conclusion Use of IVL appears to be safe and effective in dealing with calcified‐coronary lesions. A high success rate was observed with low procedural complications and event rates.
IntroductionProlonged dual anti-platelet therapy (DAPT) may cause excess bleeding in certain patients. The biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile allowing shortened DAPT. Data were gathered on the early experience implanting this stent in drug-eluting stent eligible patients deemed to be at high risk of bleeding.Background and MethodsThe demographics, procedural data and clinical outcomes were gathered prospectively for 249 patients treated with a BA9-DCS stent at 2 UK centres, and compared to a cohort of patients treated in the same period with drug-eluting stents (PCI-DES).ResultsOperator-defined BA9-DCS indications included warfarin therapy, age, and anaemia. Patients receiving a BA9-DCS were older (71.6±11.8 vs. 64.8±11.6yrs, p<0.001), more often female (38.2 vs. 26.8%, P<0.001), and more likely to have comorbidity including chronic kidney disease or poor LV function than PCI-DES patients. The baseline Mehran bleed risk score was also significantly higher in the BA9-DCS group (19.4±8.7 vs. 13.1±5.8, p<0.001). Of the BA9-DCS cohort, 95.5% of patients demonstrated disease fitting NICE criteria for DES placement. The number of lesions treated (1.81±1.1 vs. 1.58±0.92, p = 0.003), total lesion length (32.1±21.7 vs. 26.1±17.6mm, p<0.001), number of stents used (1.93±1.11 vs. 1.65±1.4, p = 0.007) and total stent length (37.5±20.8 vs. 32.4±20.3, p<0.01) were greater for BA9-DCS patients. DAPT was prescribed for 3.3±3.9 months for BA9-DCS patients and 11.3±2.4 months for PCI-DES patients (p<0.001). At follow up of 392±124 days despite the abbreviated DAPT course stent related event were infrequent with ischemia-driven restenosis PCI (2.8 vs. 3.4%, p = 0.838), and stent thrombosis (1.6 vs. 2.1%, p = 0.265) rates similar between the BA9-DCS ad PCI-DES groups. After propensity scoring all clinical end-points were similar between both cohorts.ConclusionsThis early experience using polymer-free BA9 drug-coated stents in drug-eluting stent type patients at risk of bleeding are encouraging. Further studies are warranted.
DESCRIPTIONA 72-year-old man who had undergone coronary artery bypass grafting 18 years previously (including left internal mammary artery (LIMA) graft to the left anterior descending artery) presented with an acute coronary syndrome. He underwent angiography to assess coronary artery bypass graft patency. Attempts to locate the origin of the LIMA in the left subclavian artery were unsuccessful ( figure 1A). An aortic arch angiogram was performed using a 4 Fr Pigtail catheter ( figure 1B). This revealed that the LIMA arose directly from the aortic arch, which was subsequently selectively engaged with a 5 Fr multipurpose catheter ( figure 1C).The LIMA arises from the inferior aspect of the proximal third of the subclavian artery in 92% of cases, the middle third in 7% and the distal third in 1% of cases. There are reports of the LIMA originating from the junction of the left subclavian artery and aorta, 1 and from the vertebral artery. 2 To the best of our knowledge, this is the first description of the LIMA arising directly from the aortic arch. Angiographic evaluation of the LIMA is not routinely performed prior to coronary artery bypass grafting. This case therefore exemplifies the importance of performing non-selective aortic arch angiography before concluding that the LIMA graft is occluded. Learning points▸ In a minority of cases (8%), the left internal mammary artery may not arise from the inferior aspect of the proximal third of the subclavian artery. ▸ Non-selective aortic arch angiography should always be performed prior to concluding that a left internal mammary artery graft is occluded.Competing interests None. Patient consent Obtained.Provenance and peer review Not commissioned; externally peer reviewed.
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