Sumario Vol.43 - Nº 3 Julio-Septiembre 2014 Imprimir sólo la columna central

Complicated Coronary Artery Aneurysm

Saimom É. Sgarioni, Gustavo Irusta, Daniela E. Cornejo,
Marta E. Escudero, Carolina Sobisch

Sociedad Española de Socorros Mutuos. (550) Mendoza, Argentina
E-mail
 
Recibido 07-JUN-2014 – ACEPTADO después de revisión el 04-JULIO-2014.
The authors declare not having conflicts of interest
 
Rev Fed Arg Cardiol. 2014; 43(3): 155-158
ABSTRACT

Coronary artery aneurysm is a rare disorder with dilation of a segment of the coronary artery that reaches at least 1.5 times its normal size. It is an infrequent pathology with an annual incidence between 1-2%. From a clinical point of view, its main significance is because they can produce myocardial infarction through thrombosis or its rupture. The natural history, prognosis and treatment remain uncertain. We report the case of a patient with left main coronary artery aneurysm and make an updated literature review on this subject.
Key words: Coronary artery. Aneurysm. Ectasia. Thrombosis.

 

INTRODUCTION
Coronary artery aneurysms (CAA) are a rare entity and in most cases associated to atherosclerotic disease [1]. Its clinical presentation is variable, usually with angina or myocardial infarction, and occasionally with supraventricular arrhythmia or malignant ventricular arrhythmia.

The natural history of CAA is not completely known. Significant complications have been reported in the presence of this pathology, which include thrombosis and distal embolization, ischemia or myocardial infarction, dissection, vasospasm, calcification, fistulization and very rarely rupture [2].

The diagnosis of CAA is made by coronary angiography. The single presence of this pathology does not entail the indication of surgery, which should be saved for patients with infarction and/or recurrent angina and aneurysms with a high risk of rupture [3].

 

CLINICAL CASE
The case of a 56-year-old male patient is presented, with history of hypertension, dyslipidemia, current chronic smoking, with no other relevant history, who consults in January 2013, in a peripheral center because of oppressive, retrosternal chest pain, in rest, with 8/10 intensity, with a 15-minute duration, with no irradiation or accompanying symptoms.

The patient was referred to our institution for control, diagnosis and treatment. He is admitted in a lucid state, hemodynamically compensated, blood pressure 130/70 mmHg, heart rate 55 bpm, heart rate: 16 bpm, SatO2: 96% at room air. The cardiovascular clinical examination did not show any sign of abnormality. The electrocardiogram (ECG) showed sinus bradycardia and extensive anterior and high lateral subepicardial ischemia (Figure 1), with initial levels of total CPK and CPK-MB elevated, returning to normalcy after 4 days. The echo presented dilatation of the left ventricle, with severe deterioration of contractile function (ejection fraction of 35%), anteroapical hypokinesis, with the presence of sessile apical thrombus of a small size.

Figure 1.
ECG: sinus bradycardia and signs of extensive anterior and lateral high subepicardial ischemia.


Coronary cineangriography (Figures 2 and 3) showed proximal severe, aneurysmal lesion, of the anterior descending artery, with severely affected left ventricular function. Aneurysm presents 14.7 mm long, 6.3 mm wide, with a wide neck that measures 5.25 mm. The aneurysm produces severe native artery collapse.


Figure 2. The aneurysm presents 14.7 mmof length, 6.3 mm of width, with a
wide neck measuring 5.25 mm. The aneurysm produces a severe native artery collapse


Figure 3. CABG, where bypass with left internal mammary artery
to the middle third of the anterior descending artery was performed

After 5 days from the acute event, with the diagnosis of complicated aneurysm, myocardial revascularization was indicated, with left mammary artery bypass to the anterior descending artery. At the 5th day of the uncomplicated post-operative period, in the cardiovascular recovery service, he received hospital discharge, anticoagulated, with ambulatory periodical controls.

 

DISCUSSION
This rare entity described by Morgagni in 1761, is characterized by a focal dilatation that exceeds 1.5 times the greatest diameter measured in the coronary tree of the patient [4]. Coronary artery aneurysm should be differentiated from coronary artery ectasia, which presents a more diffuse dilatation of coronary vessels, which involves at least 50% of the length of one or more vessels [5].

The prevalence of coronary artery aneurysms ranges from 0.25% in the Asian population to 2.6% in white people, although most studies estimated it in around 1-2%. It is more frequent in men, in a ratio close to 4:1. Its location is in a decreasing order of frequency in the right coronary artery [6] (RCA), circumflex artery (Cx), anterior descending artery (ADA), and common trunk of the left coronary artery. In the case presented, the lesion was located in the anterior descending artery territory, an infrequent location.
The diagnosis of this entity and/or its complications became more frequent recently, with the advancement of technology, by having coronary angiography available in a more massive way, as well as non-invasive diagnostic methods such as echography, multislice tomography, and cardiac magnetic resonance [7]. The gold standard for its diagnosis is coronary angiography.

CAA could be: simple or multiple, saccular or fusiform (Table 1) [8].

Table 1. Classification of coronary aneurysms. Mata KM, et al [10]

Characteristics

Categories

Lumen diameter of aneurysm


  • Shape

Saccular

Fusiform

Maximal transverse diameter > longitudinal dimension.
Longitudinal dimension >maximal transverse diameter.


  • Integrity of vascular wall

True aneurysm
Pseudo-aneurysm

Presence of all vascular layers.
Loss of wall integrity


  • Topographic extension

Type 1
Type 2

Type 3
Type 4

Diffuse dilatation of 2 or 3 vessels.
Diffuse dilatation in 1 vessel and located in another.
Diffuse dilatation in a single vessel.
Local or segmental dilatation


The most frequent causes in order of frequency are arteriosclerosis (50%), Kawasaki’s disease, the most frequent in childhood, and the congenital ones (Table 2) [9]. With less frequency, the following: arteritis, infections, trauma, dissection, post-coronary intervention, diseases of the connective tissue and tumoral [10].


Table 2. Most frequent causes of coronary aneurysms. [9]
  • Atherosclerosis

  • Congenital

  • Inflammatory diseases
    Kawasaki, Takayasu. SLE, RA, APS, Wegener’s granulomatosis, giant cell arteritis, Churg-Strauss.
  • Connective tissue disease
    Marfan syndrome, Ehlers-Danlos syndrome,
    Fibromuscular dysplasia.
  • Infectious
    Bacterial, fungal, syphilis, Lyme, HIV, septic embolism, mycotic aneurysm.
  • Related to drugs
    Cocaine, amphetamines.
  • Traumatic

  • Iatrogenic

LES: Systemic lupus erythematous; RA: Rheumatoid arthritis
APS: Antiphospholipid syndrome; HIV: Human immunodeficiency virus.


Gutowski T et al, claim that the presence of the different risk factors (hypertension, diabetes, dyslipidemia, family history of CAD, smoking and the presence of peripheral artery disease) in patients with coronary artery aneurysms, does not differ when compared to patients with CAD without aneurysms.

The pathophysiology of CAA is linked to an abnormality at the level of the tunica media of the coronary vessel artery wall, resulting from an intimal atherosclerotic process, that includes erosion, ulceration, and bleeding. Moreover, it could be associated to an alteration in the release of vasoactive substances as nitric oxide. Coronary artery spasm is infrequent, since the artery wall does not have enough intact smooth muscle [11].

CAA manifest clinically with a greater frequency with angina and myocardial infarction, but other less typical presentations are dyspnea, dysphagia and syncope. It is important to suspect it in young patients with history of Kawasaki’s disease, or other connective tissue diseases.

The gold standard to diagnose and detect CAA is coronary arteriography, which allows evaluating size, location, affected main and secondary vessels, presence of associated fistulae, and characteristics of flow, as well as the presence of associated obstructive CAD. The prognosis of these patients depends on the presence, severity and complications of the concomitant artery disease.

The therapeutic options include surgical, percutaneous or medical treatment. The treatment should be individualized, depending on the size, location and complications of the aneurysm, as well as on the clinical symptoms of the patient [12].

In adults, surgical treatment is the preferred therapeutic option, and the technique most used, with the coronary bypass implant, with or without aneurysm ligation [13].

In the reported case, CABG was performed, with left mammary artery bypass to the anterior descending artery (Figure 4).

Figure 4. Coronary cineangiography that shows severe, complicated,
aneurysmal lesion of the proximal anterior descending artery

 

The ligation is especially difficult in those cases in which the main trunk is involved, where hybrid therapy with surgical revascularization and subsequent aneurysm occlusion by endovascular therapy has been attempted, since coated stents effectively seal the aneurysm and offer a safe and less invasive alternative [14].

Surgery is recommended in patients with infarction, recurrent angina, and aneurysms with high risk, a risk increased in the cases of saccular and large aneurysms, or in the presence of compression symptoms and in patients with severe arteriosclerotic disease that require CABG.

The pharmacological therapy consists on antiplatelet medication, anticoagulation, and vasodilators [15]. Of course, it is indispensable to have a strict control on the cardiovascular risk factors.

 

CONCLUSIONS
The coronary artery aneurysms are an infrequent entity that in the great majority of cases are associated to atherosclerotic disease, as in the reported case. Coronary artery angiography allows to know accurately its location, size and assess the characteristics of the coronary lesion, in this case with severe collapse of the native artery. This typification, undoubtedly contributes to the decision to be made, as it was done, on CABG by coronary artery bypass by the mammary artery into the anterior descending artery.

 

REFERENCES

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  12. Coronaryarteryaneurysms in acutecoronarysyndrome: case series, review, and proposedmanagementstrategy.Boyer N, Gupta R, Schevchuck A, et al. J InvasiveCardiol2014;26(6):283-90.
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Publication: September 2014



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