Case Report
Giant coronary aneurysm culprit of an acute coronary syndrome
Aneurisma coronário gigante como lesão alvo de uma síndrome coronária aguda
Iván J. Núñez-Gil
, Pedro Marcos Alberca, Nieves Gonzalo, Luis Nombela-Franco, Pablo Salinas, Antonio Fernández-Ortiz
Corresponding author
Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Núñez-Gil, Pedro Marcos Alberca, Nieves Gonzalo, Luis Nombela-Franco, Pablo Salinas, Antonio Fernández-Ortiz" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" "email" => array:1 [ 0 => "ibnsky@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Pedro Marcos" "apellidos" => "Alberca" ] 2 => array:2 [ "nombre" => "Nieves" "apellidos" => "Gonzalo" ] 3 => array:2 [ "nombre" => "Luis" "apellidos" => "Nombela-Franco" ] 4 => array:2 [ "nombre" => "Pablo" "apellidos" => "Salinas" ] 5 => array:2 [ "nombre" => "Antonio" "apellidos" => "Fernández-Ortiz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma coronário gigante como lesão alvo de uma síndrome coronária aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3067 "Ancho" => 1733 "Tamanyo" => 776454 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A) Angiographic comparison (spider view). Pre-treatment. The white arrow points out the aneurysm's neck area. B) Final angiographic result. C) Initial IVUS LCx imaging study. D) Initial OCT LCx imaging pullback. E) Final IVUS LCx imaging pullback. F) Final OCT LCx imaging pullback.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery aneurysm is defined as a coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. A giant coronary aneurysm is usually defined as a dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 4 times. Described by Bourgon<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>, it is a rare disease which has been diagnosed with increasing frequency since the advent of coronary angiography<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a>. The incidence has been deemed to vary from 1.5% to 5% with male dominance and a predilection for the right coronary artery<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">With several unanswered questions, coronary aneurysms are managed in several ways (conservative, stenting or cardiac surgery)<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–6</span></a>. Here, we present a case with a giant coronary aneurysm in a culprit vessel in an acute coronary syndrome setting.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 66-year-old male ex-smoker with hypertension, type 2 diabetes mellitus and dyslipidaemia, without history of trauma, vasculitis or connective tissue disorders, was admitted due to a non-ST segment elevation myocardial infarction with mild troponin I elevation (Grace 2.0: 93; estimated 1-year mortality 3.1%; estimated 3-year mortality: 7.1%; Crusade: 27, 6.1% bleeding risk). The ECG showed sinus rhythm with lateral negative T waves, a transthoracic echocardiogram revealed normal left ventricular ejection fraction and the cardiac catheterisation depicted an extensive and calcified coronary disease, including a chronic total obstruction at the proximal segment of the right coronary artery together with a severe and diffuse disease with a giant aneurysm at the first obtuse marginal branch as the culprit lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), TIMI flow III. The left anterior descending artery revealed no significant stenosis. Since the patient remained stable on medical treatment, we decided further study was necessary and a coronary CT was ordered, confirming the previous findings (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A-B) and highlighting a giant saccular coronary aneurysm (17x14<span class="elsevierStyleHsp" style=""></span>mm) with a wide neck at a big obtuse marginal level.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Thus, the following treatment options were considered to treat the patient: coronary artery bypass grafting (CABG), coil embolisation or stent implantation (covered). CABG was discarded because the left anterior descending artery was free of severe disease and the less-invasive interventional approach was preferred by the patient and his family. Treatment dilemmas at this point were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Right coronary artery chronic total occlusion.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">Technical difficulty in closing the aneurysm, with a small branch arising from its neck.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Wide neck posing some issues regarding the use of coils, together with severe, calcified and diffuse lesions before the aneurysm.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">Thus, we decided on the “covered or graft” stent option. First, we performed the interventional procedure on the right coronary artery chronic total occlusion. Using a regular anterograde approach, 2 drug-eluting stents (DES) were successfully implanted. Later on, we selected the Papyrus® stent (Biotronik, Germany), a single layer covered (90<span class="elsevierStyleHsp" style=""></span>μm polyurethane porous layer) stent based on the Orsiro/Prokinetic platform, which is supposed to achieve a greater bending flexibility and deliverability, and is designed to treat coronary perforations.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Then, intracoronary imaging (IVUS, Boston-Scientific, MA, USA; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C and OCT, St Jude, St. Paul, Minn., USA; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D), was performed, depicting a severely diseased and calcified vessel, with a tight calcified stenosis (ALM:1.78<span class="elsevierStyleHsp" style=""></span>cm2), previous to the neck of the aneurysm. A first attempt to cross the graft directly failed, probably because of marked tortuosity. The whole vessel was consecutively predilated with a 2.5x12<span class="elsevierStyleHsp" style=""></span>mm balloon. A mother-and-child system was then advanced (6F-Guideliner, Vascular Solutions Inc., Minn., USA), allowing to cross the lesion with the stent-graft (3.5x20<span class="elsevierStyleHsp" style=""></span>mm) and its proper positioning (14atm). Later, two DES were consecutively implanted, covering all the LCx stenosis, including the stent graft, with a good angiographic outcome and complete aneurysm obliteration, <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B. In addition, implanting a DES inside the stent-graft could hopefully potentially diminish the proliferative/thrombotic trend described for these covered scaffolds.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The result was optimised with several high pressure 3.5x15<span class="elsevierStyleHsp" style=""></span>mm noncompliant balloon inflations, with a good angiographic outcome. This was double-checked with intracoronary imaging (IVUS; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E and IVUS; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient remained free from angina and was discharged 48<span class="elsevierStyleHsp" style=""></span>hours post-intervention, with an asymptomatic mild troponin increase due to the (deliberate) closure of the small branch located near the aneurysm's neck. A 3-month follow-up coronary CT-scan showed the persistence of the good outcome, with complete aneurysm closure (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C-E). The patient was discharged on aspirin and ticagrelor (12 months). At 12-month follow-up the patient was in NYHA functional class I without angina, and the control angiogram confirmed the stents’ patency.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Although several causes have been reported, atherosclerosis is the most prevalent, accounting for more than 50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolisation, rupture and vasospasm, causing ischaemia, heart failure, arrhythmias and, less frequently, compression of surrounding structures and fistulisation into one of the cardiac chambers. In addition, controversy persists regarding the use of medical management (antithrombotic) or interventional/surgical procedures<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–8</span></a>. Sometimes, the aneurysm concept is confused or mixed with “ectasia”. The term ‘ectasia’ refers to a diffuse dilation of a coronary artery, while focal dilation is properly called ‘coronary aneurysm’<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>. This condition has been suggested as a variant of coronary atherosclerosis<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Occasionally, the clinical presentation is acute, like in our case. Consequently, we need to have, in advance, detailed protocols and guidelines in these cases warranting prompt and quick management. Interventional cardiology advances, with new techniques and devices, such as in our case, are beginning to make less-invasive treatment feasible for complex patients with aneurysms. The new intracoronary imaging techniques provide a unique opportunity to guide and improve our interventional procedures. In our case, we decided to opt for the multivessel interventional option because the left anterior descending artery was free of severe disease, and we used both IVUS and OCT for academic purposes.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nevertheless, the natural history and long-term prognosis remains obscure, since definitive data are scarce. Therefore, until we have the results of the currently ongoing international registry on coronary artery aneurysm (CAAR, ClinicalTrials.gov Identifier: NCT02563626), we can only adopt an empirical approach, based on small series or case reports.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Here, we propose an alternative to simply manage a potentially complex condition from an interventional point of view in an acute setting guided by the unique contribution of intracoronary imaging.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1005675" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec965461" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1005674" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec965462" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-28" "fechaAceptado" => "2016-11-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec965461" "palabras" => array:6 [ 0 => "Acute coronary syndrome" 1 => "Coronary aneurysm" 2 => "OCT" 3 => "IVUS" 4 => "CT-scan" 5 => "Multimodality" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec965462" "palabras" => array:6 [ 0 => "Síndrome coronária aguda" 1 => "Aneurisma coronário" 2 => "OCT" 3 => "IVUS" 4 => "CT-Scan" 5 => "Multimodalidade" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 66-year-old male ex-smoker with hypertension, type 2 diabetes mellitus and dyslipidaemia was admitted due to a non-ST segment elevation myocardial infarction. The catheterisation depicted an extensive and calcified disease: chronic total obstruction of the right coronary and severe disease with a giant aneurysm at the first marginal branch as the culprit vessel. After discussion, the right coronary was treated before the circumflex-giant aneurysm was closed with a stent graft and its multiple severe stenosis solved with two drug-eluting stents. We provide a multimodality approach for a complex case and briefly discuss the available options.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Um homem de 66 anos, ex-fumador, hipertenso, com diabetes tipo II e dislipidemia, foi admitido por enfarte do miocárdio sem supradesnivelamento de ST. O cateterismo revelou doença extensa e calcificada: oclusão crónica e total da artéria coronária direita e doença severa com aneurisma gigante da primeira obtusa marginal, como lesão alvo. Após discussão, foi tratada a artéria coronária direita e posteriormente foi encerrado o aneurisma gigante de circunflexa com um <span class="elsevierStyleItalic">stent</span> e as suas múltiplas estenoses severas foram resolvidas com dois <span class="elsevierStyleItalic">stents</span> com fármaco. Providenciamos uma abordagem multimodal para um caso complexo e discutimos brevemente as diferentes opções possíveis.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3067 "Ancho" => 1733 "Tamanyo" => 776454 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A) Angiographic comparison (spider view). Pre-treatment. The white arrow points out the aneurysm's neck area. B) Final angiographic result. C) Initial IVUS LCx imaging study. D) Initial OCT LCx imaging pullback. E) Final IVUS LCx imaging pullback. F) Final OCT LCx imaging pullback.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2297 "Ancho" => 1733 "Tamanyo" => 359301 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary CT scan aneurysm characterisation. A) LCx maximum pixel intensity multiplanar reconstruction or MIP-MPR. B). Cardiac 3D volume rendering oriented like cranial RAO showing LCx and aneurysm. C) 3-month-follow-up coronary CT scan. LCx centreline curved multiplanar reconstruction. D) LCx 3D rendering. E) LCX straight line reconstruction derived from curved centreline. MPR (so called virtual IVUS). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 5 | 16 |
| 2024 October | 33 | 27 | 60 |
| 2024 September | 38 | 22 | 60 |
| 2024 August | 42 | 23 | 65 |
| 2024 July | 30 | 30 | 60 |
| 2024 June | 26 | 17 | 43 |
| 2024 May | 37 | 30 | 67 |
| 2024 April | 26 | 28 | 54 |
| 2024 March | 30 | 23 | 53 |
| 2024 February | 35 | 23 | 58 |
| 2024 January | 17 | 17 | 34 |
| 2023 December | 26 | 26 | 52 |
| 2023 November | 23 | 19 | 42 |
| 2023 October | 18 | 11 | 29 |
| 2023 September | 30 | 12 | 42 |
| 2023 August | 18 | 24 | 42 |
| 2023 July | 28 | 12 | 40 |
| 2023 June | 20 | 8 | 28 |
| 2023 May | 38 | 20 | 58 |
| 2023 April | 30 | 8 | 38 |
| 2023 March | 46 | 31 | 77 |
| 2023 February | 29 | 17 | 46 |
| 2023 January | 36 | 15 | 51 |
| 2022 December | 47 | 19 | 66 |
| 2022 November | 62 | 33 | 95 |
| 2022 October | 40 | 19 | 59 |
| 2022 September | 42 | 40 | 82 |
| 2022 August | 84 | 30 | 114 |
| 2022 July | 91 | 52 | 143 |
| 2022 June | 29 | 30 | 59 |
| 2022 May | 50 | 30 | 80 |
| 2022 April | 58 | 32 | 90 |
| 2022 March | 40 | 42 | 82 |
| 2022 February | 71 | 37 | 108 |
| 2022 January | 62 | 31 | 93 |
| 2021 December | 46 | 31 | 77 |
| 2021 November | 47 | 28 | 75 |
| 2021 October | 49 | 47 | 96 |
| 2021 September | 54 | 33 | 87 |
| 2021 August | 37 | 28 | 65 |
| 2021 July | 27 | 24 | 51 |
| 2021 June | 27 | 10 | 37 |
| 2021 May | 42 | 40 | 82 |
| 2021 April | 65 | 41 | 106 |
| 2021 March | 90 | 16 | 106 |
| 2021 February | 53 | 20 | 73 |
| 2021 January | 35 | 14 | 49 |
| 2020 December | 35 | 12 | 47 |
| 2020 November | 36 | 8 | 44 |
| 2020 October | 26 | 13 | 39 |
| 2020 September | 53 | 12 | 65 |
| 2020 August | 41 | 11 | 52 |
| 2020 July | 58 | 12 | 70 |
| 2020 June | 42 | 6 | 48 |
| 2020 May | 47 | 9 | 56 |
| 2020 April | 37 | 5 | 42 |
| 2020 March | 62 | 11 | 73 |
| 2020 February | 120 | 14 | 134 |
| 2020 January | 44 | 6 | 50 |
| 2019 December | 28 | 6 | 34 |
| 2019 November | 42 | 7 | 49 |
| 2019 October | 63 | 5 | 68 |
| 2019 September | 58 | 10 | 68 |
| 2019 August | 31 | 5 | 36 |
| 2019 July | 39 | 14 | 53 |
| 2019 June | 40 | 8 | 48 |
| 2019 May | 35 | 14 | 49 |
| 2019 April | 31 | 20 | 51 |
| 2019 March | 72 | 10 | 82 |
| 2019 February | 56 | 5 | 61 |
| 2019 January | 42 | 12 | 54 |
| 2018 December | 72 | 12 | 84 |
| 2018 November | 55 | 11 | 66 |
| 2018 October | 50 | 14 | 64 |
| 2018 September | 26 | 11 | 37 |
| 2018 August | 37 | 6 | 43 |
| 2018 July | 29 | 3 | 32 |
| 2018 June | 34 | 4 | 38 |
| 2018 May | 30 | 3 | 33 |
| 2018 April | 67 | 15 | 82 |
| 2018 March | 43 | 11 | 54 |
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