Treatment of Giant Coronary Aneurysms

A 58-year-old man presented with NSTEMI… Wilkinson JS et al. Exp Clin Cardiol. 2012 Summer;17(2):69-73. RAO angiogram A clot-filled aneurysm as well as a filling defect of the ostial septal (Sp) showing embolization of the clot (thin black arrow).

Multislice CT showing a large aneurysm measuring 3. 0 cm × 1. 8 cm × 1 Multislice CT showing a large aneurysm measuring 3.0 cm × 1.8 cm × 1.6 cm. Filling defect is shown in the aneurysmal segment of the LAD (large arrow) as well as a filling defect in the septal perforator (Sp) (small arrow).

Intraoperative photograph. The surgical pathology report described benign fibromuscular tissue representing true aneurysmal dilation of the LM with extension into the LAD

Pathogenesis Destruction and weakening of the media layer Chronic overstimulation with endogenous NO Ulceration and remodelling consistent with advanced atherosclerosis Direct effect of elevated inflammatory mediators (specifically MMP)

Etiologies Atherosclerosis (is the most common, AAA is common in these patients) Various vasculitides (Kawasaki, polyarteritis nodosa, Takayasu) Connective tissue disorders(such as Ehlers-Danlos) Sepsis (leading to mycotic aneurysm) Trauma Cocaine use

Clinical Presentation Incidental finding in chest imaging Angina Acute coronary syndrome Arrhythmia Distal coronary obstruction Aneurysm rupture Superior vena cava syndrome

Classification Sizes: small (<5 mm), medium (5 mm to 8 mm) or giant (>8 mm). there is little evidence that there is a relationship between increased mortality risk and aneurysm size (Antoniadis AP et al. Pathogenetic mechanisms of coronary ectasia. Int J Cardiol. 2008;130:335–43). Morphology: fusiform or saccular in shape. Presence of concomitant stenosis: Markis system classification included the number of coronary arteries involved (Markis JE et al. Clinical significance of coronary arterial ectasia. Am J Cardiol. 1976;37:217–22).

Diagnosis Coronary angiography: Has several limitations for evaluating aneurysmal disease Misleading in low-flow areas Formation of acute clots may obscure the true angiography result (false negative) Pseudoaneurysms mimicking a true aneurysm Multislice CT: Can differentiate a true aneurysm from a dissection leading to a false aneurysm Assist in surgical planning- demonstrate vascular structures in the context of surrounding tissue (branches involved, pulmonary artery proximity).

Diagnosis C-MRI: Has been described in a patient with known Kawasaki disease who presented with a thrombosed aneurysm presenting as a myocardial infarction (Int J Cardiol. 2010;144:286–8.). OCT/IVUS: Although both modalities have been described in identifying spontaneous coronary artery dissection, OCT’s higher spatial resolution allows for more accurate and sensitive detection of dissection planes (Kubo T, et al. JACC Cardiovasc Imaging. 2008;1:475–84, Poon K et al. Circ Cardiovasc Interv. 4:e5–7.)

Management Only few studies have thoroughly examined the natural history of GCA, which has made the management of these lesions controversial. Warfarin- no studies to advise for or against the use of in patients with GCA. However, given the common presentation of high burden of clot, many advocate life-long warfarin therapy.

Coronary artery ectasia does not confer added risk in patients with coexisting obstructive coronary artery disease. Although there is a measurable incidence of previous MI, patients with pure ectasia have a good prognosis.

Am J Cardiol. 2004 Jun 15;93(12):1549-51. Aneurysms are independent predictors of mortality, with 71% of patients surviving after five years.

Subgroup analysis from the CASS: reported similar survival in patients who had undergone CABG versus medical therapy in both the aneurysm and stenosis only groups. The best recommendation to date is intervention only in patients with high-risk features of myocardial compromise.

Management Nonurgent care patients Those in whom aneurysms are found incidentally, are asymptomatic, have reassuring ECGs or have negative cardiac enzyme investigations. Some advocate prospective follow-up using CT. Patients who require urgent care Those who present with unstable symptoms, an abnormal ECG, a rise in cardiac enzyme levels, or show signs of impeding compromise including intra-aneurysmal thrombosis or dissection. Both surgical and percutaneous methods of intervention have been described.

Summary GCA are uncommon malformations that can occur in a variety of disease states but are usually due to atherosclerosis. Definitive diagnosis with invasive angiography may be difficult and CT angiography provides a better assessment. Unstable patients should be treated (Bypass>PCI). Stable patients should probably be managed conservatively. Coumadin should be advocated.

Management Difficult management decisions are compounded due to the presence of concomitant stenosis, the diverse anatomical involvement, aneurysm morphological differences, and acute complications such as thrombosis, plaque rupture or dissection. From a surgical perspective, pertinent questions are whether a vessel should be ligated, whether aneurysm should be excised or plicated, and whether the thrombus should be removed.