How should I treat multiple coronary aneurysms with severe stenoses?

Abstract

A 46-year-old male, with a history of old myocardial infarction (MI) in the first diagonal branch (D1) treated with balloon angioplasty three years before, was admitted to our institution because of chest pain on effort. Coronary angiography revealed coronary artery aneurysms measuring approximately 10 mm and 7 mm in the left anterior descending artery (LAD) and D1, respectively (Figure 1A), which were not clearly detected three years before. Moreover, significant stenoses were also demonstrated proximal to both aneurysms, distal to the D1 aneurysm, and in the obtuse marginal (OM) branch (Figure 1A, Figure 1B). The fractional flow reserve (FFR) in the LAD was 0.50, as measured with PressureWire™‚ Certus™ (St. Jude Medical, St. Paul, MN, USA) (Figure 1C). Electrocardiography showed a Q-wave in I, aVL, which indicated transmural MI in the D1 region (Figure 2A). Echocardiography showed thinness of the wall with akinetic motion in the anterolateral left ventricular wall. The left ventricular ejection fraction was 53% and there was no valvular pathology. 201Tl-123I-BMIPP scintigraphy demonstrated no viability in the D1 region (Figure 2B). Coronary angiography (Figure 2C) was performed in approximately the same view as the coronary computed tomography (Figure 2D) to be easily compared. Reststress myocardial perfusion scintigraphy showed ischaemia in the LAD and OM regions, and transmural MI in the D1 region. The fusion image of coronary computed tomography and scintigraphy

Unexpected evolution of a non-stenotic lesion in the left main coronary artery of a patient with non–ST-segment elevation myocardial infarction

“…Since the first reported case in 1998 by Von Birgelen et al (6), several documented procedures of successful percutaneous exclusion of coronary aneurysms using polytetrafluoroethylene-covered (PTFE) stents have been disclosed (7-10). Other authors have documented successful treatment of coronary aneurysms using coil embolization (11,12) when associated stenoses requiring PCI are frequently encountered (11). In the presence of a collateral branch connected to the main coronary artery affected by the aneurysm, it would be necessary to take into account a collateral in-flow, resulting in the persistence of permeability of the aneurysm (11 In our case, the Heart Team facilitated the decisionmaking process.…”

Rationale and design of a multicenter, international and collaborative Coronary Artery Aneurysm Registry (CAAR)

“…With very limited information about this potentially severe and complex disease, the only data available are based on clinical cases, small series, or post‐hoc substudies from other research, usually noncontemporary, with different profiles and probably different therapeutics . Thus, when diagnosing a coronary aneurysm (acutely or not), there is no clear therapeutic approach and prognostic data.…”

“…With very limited information about this potentially severe and complex disease, the only data available are based on clinical cases, small series, or post-hoc substudies from other research, usually noncontemporary, with different profiles and probably different therapeutics. [10][11][12][13][14][15] Thus, when diagnosing a coronary aneurysm (acutely or not), there is no clear therapeutic approach and prognostic data. In fact, it is remarkable that coronary artery disease practice guidelines do not refer to this condition and do not provide recommendations at all, even in acute settings.…”

Late lumen enlargement induced by drug coated balloon in the patient with PTFE‐covered stent restenosis

“…We had already reported successful physiological‐guided coronary intervention with polytetrafluoroethylene (PTFE)‐covered stent implantation and coil embolization for the patient with multiple stenoses and coronary artery aneurysms in 2014 . A 2.8 × 26 mm PTFE‐covered stent (JOSTENT™ GraftMaster; Abbot Vascular, Santa Clara, CA) was implanted to the proximal left anterior descending artery.…”

“…We had already reported successful physiological-guided coronary intervention with polytetrafluoroethylene (PTFE)-covered stent implantation and coil embolization for the patient with multiple stenoses and coronary artery aneurysms in 2014 [3]. OCT just after the procedure showed minimum stent area of 6.18 mm 2 and paclitaxel particle adhering to the vessel wall (Figure 2a).…”