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Coronary artery aneurysm presenting as acute coronary syndrome: two case reports and a review of the literature

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Abstract

Coronary artery aneurysm (CAA) is an uncommon coronary disease, with a reported incidence in adults ranging from 0.33 to 4.9%.It is usually considered a variant of coronary artery disease (CAD). CAA is associated with thrombus formation due to abnormal laminar flow, as well as abnormal platelet and endothelial-derived pathophysiologic factors within the CAA. CAA identified in the context of acute coronary syndrome (ACS) poses several unique management challenges. Optimal antiplatelet and anticoagulant therapy is the mainstay of therapy. Percutaneous intervention for CAA is associated with complications including distal embolization of thrombus, no-reflow phenomenon, stent malposition, dissection, and rupture. There are currently no accepted guidelines to direct the management of CAA in patients presenting with ACS. Preference for conservative vs. surgical or catheter-based management is controversial. We review the literature and report different treatment strategies for two cases with both CAA and ACS.

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Abbreviations

ACS:

Acute coronary syndrome

CAA:

Coronary artery aneurysm

CAD:

Coronary artery disease

CABG:

Coronary artery bypass graft surgery

DAPT:

Dual antiplatelet therapy

IVUS:

Intravascular ultrasound

LV:

Left ventricle

NSTEMI:

Non-ST-elevation myocardial infarction

PCI:

Post percutaneous coronary interventions

PTFE:

Polytetrafluoroethylene

STEMI:

ST elevation myocardial infarction

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Authors and Affiliations

  1. Division of Cardiology, MercyOne-Iowa Heart Center, 1111 6th Ave, Des Moines, IA, 50314, USA

    Tuncay Taskesen, Kofi Osei, Justin Ugwu, Russell Hamilton, Mark Tannenbaum & Magdi Ghali

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  1. Tuncay Taskesen
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  2. Kofi Osei
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  3. Justin Ugwu
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  4. Russell Hamilton
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  5. Mark Tannenbaum
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  6. Magdi Ghali
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Correspondence to Tuncay Taskesen.

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Video 1a Coronary angiogram: left anterior oblique view of RCA was notable for proximal RCA CAA with visible thrombus within the aneurysm sac (arrow) in a patient with acute coronary syndrome. (AVI 2642 kb)

Video 1b Coronary angiogram was notable for coronary fistula between Conus branch of RCA and pulmonary artery. (AVI 2134 kb)

Video 1c Intravascular ultrasound (IVUS) shows true lumen in RCA proximal. (AVI 17600 kb)

Video 1d Coronary angiogram: left anterior oblique view of RCA after insertion of covered 4.5 mm x 19 mm stent (arrow) to the proximal RCA. RCA proximal thrombus and obstruction resolved, aneurysm excluded, and TIMI 3 flow was obtained. (AVI 3788 kb)

Video 2a Coronary angiogram of left coronary artery in anterior posterior view shows LCX proximal/mid coronary artery aneurysm (white arrow) and significant thrombus burden (black arrow) and obstruction in mid LCX and OM2 branch in patient with acute coronary syndrome. (AVI 845 kb)

Video 2b Coronary angiogram of left coronary artery in LAO caudal view shows LCX proximal/mid coronary artery aneurysm and significant thrombus burden and obstruction in mid LCX and OM2 branch in patient with acute coronary syndrome. (AVI 734 kb)

Video 2c Coronary angiogram of left coronary artery in anterior posterior view shows LCX proximal/mid coronary artery aneurysm and resolution of thrombus and obstruction in mid LCX and OM2 branch in patient with acute coronary syndrome after intensive antiplatelet and anticoagulant therapy. (AVI 548 kb)

Video 2d Coronary angiogram of left coronary artery in LAO caudal view shows LCX proximal/mid coronary artery aneurysm and resolution of thrombus and obstruction in mid LCX and OM2 branch in patient with acute coronary syndrome after intensive antiplatelet and anticoagulant therapy. (AVI 574 kb)

Video 2e Coronary angiogram of left coronary artery in RAO caudal view shows significant thrombus burden and mid LCX and side branches with TIMI 2 flow in patient with acute coronary syndrome. (AVI 709 kb)

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Taskesen, T., Osei, K., Ugwu, J. et al. Coronary artery aneurysm presenting as acute coronary syndrome: two case reports and a review of the literature. J Thromb Thrombolysis 52, 683–688 (2021). https://doi.org/10.1007/s11239-021-02418-2

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  • DOI: https://doi.org/10.1007/s11239-021-02418-2

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