• Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results

    Abstract

    Background

    Coronary aneurysms (1.5 times dilation the reference-vessel) are uncommon and have been diagnosed with increasing frequency with coronary angiography. The incidence varies from 1.5% to 5%. Reported complications are multiple: thrombosis, distal embolization, rupture and vasospasm, causing ischemia, heart failure or arrhythmias. However, the natural history and prognosis remains obscure. We aimed to describe the characteristics of acute patients with coronary aneurysms.

    Methods

    Prospective coronariography registry of patients with the diagnosis of coronary aneurysm between 2002 and 2013. Among 51,555 consecutive coronary angiograms, 414 patients with aneurysms were reported, of which 256 were considered acute (82% NSTE-ACS).

    Results

    Predominantly male (80%, mean age 65.5 years), cardiovascular risk factors were common (hypertension 65%, dyslipidemia 65%, obesity 25%, diabetes mellitus 28.5%, and smokers 67%). With frequent coronary stenoses (94%), mostly with one aneurysm (80%), it was observed more frequently in the anterior descending artery. After a median follow-up of 52 months, 53 died (14 cardiac causes) and 42% presented a cardiovascular event. Complications from the aneurysm were found in 4. The duration of dual antiplatelet therapy, LVEF, age and peripheral vascular disease highlighted in the multivariate analysis of death.

    Conclusion

    The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low. Patients who present them also have a large burden of atherosclerotic risk factors. In the long-term, the probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself. A more intense and prolonged antithrombotic treatment may result in lower mortality rates.

    Highlights

     

    •  

      Coronary aneurysms are uncommon and have been diagnosed with increasing frequency with coronary angiography.

    •  

      We describe the characteristics and long term follow up of acute patients with coronary aneurysms between 2002-2013.

    •  

      The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low.

    •  

      Long-term probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself.

     

    Introduction

    Coronary aneurysm were classically defined as that segment of the artery in which dilation exceeds over 1.5 times the diameter of an adjacent portion, considered as a reference point. It is a rare disease, the diagnosis of which developed with the use of imaging techniques capable of performing coronary angiography, usually with invasive procedures (coronary angiography).

    First described by Bourgon  , we do not have much data and what we have derives primarily from small case series. Its incidence has been estimated around 1.5–5% of the population  , with male dominance and a reported preferential location in the right coronary artery (RCA). The etiology is not fully clear and many causes have been suggested, of which atherosclerosis is the most commonly held among adults, accounting up to 50% .

    Although in many cases the aneurysms are incidental findings in acute patients, nonetheless many complications derived from them, such as local thrombosis, distal embolization, rupture and vasospasm with secondary genesis of ischemia, heart failure and arrhythmias  , have been reported.

    The natural history and long-term prognosis remain a mystery, while the optimal management, from the medical point of view (antithrombotic), either as interventional or surgical remains to be clarified  .

    According to the classic definition of coronary aneurysm, in this paper we would propose to:

    •  

      Characterize the frequency, anatomy, type and location of coronary aneurysms in invasive coronary angiography performed for any reason in our environment.

    •  

      Describe the clinical characteristics of acute care, treatment chosen by treating doctors and the subsequent long-term clinical outcome of the patient.

     

    Material and methods

    We retrospectively selected all those patients who underwent coronary angiography during the time period between 1 January 2002 and 31 December 2013, and who had the possible diagnosis of coronary aneurysm from a prospective multipurpose database. As an inclusion criterion, we used the classically accepted definition that considers coronary aneurysm as a localized dilatation of an artery segment exceeding over 1.5 times the diameter of an adjacent portion. Giant aneurysm was that one which reached 4 times the reference diameter. The presence of coronary ectasia itself, that is, a non-focal coronary dilatation or without clear aneurysms, was considered as exclusion criteria.

    Once all the possible candidates were obtained, images of coronary angiography were reviewed (ING, DB, BT) to ultimately record 414 patients with at least one coronary aneurysm. We then selected acute patients, e.g., those whose symptoms required an emergent, urgent invasive coronary angiography, or with destabilization of symptoms within the previous month. Thus, for the purposes of this paper, we included the following diagnoses as acute situations where the indication for catheterization was determined by their treating physician: unstable angina, recent myocardial infarction (with or without ST-segment elevation) cardiogenic shock, syncope or sudden death, Fig. 1 

    Fig. 1
    Flowchart of patients analyzed with the diagnosis of coronary aneurysm established by invasive coronary angiography and finally included in the study (acute patients, see definition in the text).
    STEMI: ST-elevation myocardial infarction; NSTEMI: non ST-elevation myocardial infarction; pre-op: preoperative; LV: left ventricle; PCI: percutaneous coronary intervention.

     

    We compared the number of patients with the number of coronary angiographies performed in our network of interventional cardiology with the aforementioned structure  in order to calculate the approximate incidence of disease in our area. The clinical and therapeutic features and complications during hospitalization were carefully collected, as well as the long-term monitoring. The monitoring was performed prospectively either in person or by telephone clinical consultations. The treatment, in all cases, was determined by the attending physicians. We considered the following events with regard to patient follow-up: the death of cardiovascular and all-cause, the need for rehospitalization for unstable angina, myocardial reinfarction, heart failure, arterial thromboembolism, stroke or clinically relevant bleeding (Bleeding Academic Research Consortium, BARC 2, 3 or 5). In addition, a combined-variable called MACE that included any of the following was considered: death and/or unstable angina and/or myocardial reinfarction and/or heart failure and/or stroke.

    The monitoring was closed after the first quarter of 2016. As a control group, we collected, similar to the above description, clinical data and monitoring of 500 consecutive patients that underwent coronary angioplasty in our hospital with the diagnosis of acute coronary syndrome (unstable angina, non-ST or ST elevation –STE-ACS) during 2011. This information was collected in an electronic data collection notebook. The study was approved by the ethical committee of our center (15/458-E).

    Statistic analysis

    For statistical analysis we used the SPSS v24.0 (IBM-SPSS, USA) and OFFICE 2010 software package (Microsoft, USA). The data is presented as mean ± standard deviation or median and range, as applicable. The study is basically descriptive and differences between groups were analyzed using the most appropriate statistic in each case, specifying in the text, according to data spread and depending on whether it included quantitative or qualitative variables. Comparisons between groups were performed using the Pearson chi square for qualitative variables and the Student- -test for continuous variables. Long term survival curves for the different groups were obtained using the Kaplan-Meier method and comparisons between groups were performed using the log-rank test. Regarding the multivariate analysis, Cox logistic regression was used to analyze and select those variables independently associated with the development of long-term clinical events. To avoid excess of variables included in the multivariate analysis, these were reduced using a pre-specified model including those variables that obtained a value of p ≤ 0.10 in univariate study, as shown in the results section. Regarding the probability of death during follow-up, the results of the specific model that included the following variables are explained: hypertension, diabetes mellitus, renal impairment (creatinine clearance calculated by Cockcroft-Gault < 30 ml/min), peripheral vascular disease, arterial aneurysms in non-coronary areas, presence of coronary disease, age (in quartiles), LVEF (in increasing quartiles), duration of dual antiplatelet therapy (in increasing quartiles) and type of treatment (conservative, simple angioplasty, bare-metal or drug-eluting stents, or coronary surgery). As for MACE, the multivariate model was compiled with: dyslipidemia, renal impairment (creatinine clearance calculated by Cockcroft-Gault < 30 ml/min), peripheral vascular disease, arterial aneurysms in non-coronary areas, presence of coronary disease, age (increasing quartiles), LVEF (in increasing quartiles), and the use of aspirin at discharge.

    Risk ratios (hazard ratio, HR) and confidence intervals (CI) were calculated at 95% according to the backward stepwise logistic regression analysis (Wald). Finally, we selected a cohort of 500 consecutive patients admitted because an acute coronary syndrome in 2011, and treated with stent for control purposes. To adjust for any potential bias, propensity score matching was performed using a logistic (binary) regression model. The level of statistical significance was set at p < 0.05 (two-tailed).

    Results

    Procedures and patient flow

    During the period under consideration, 51,555 invasive coronary angiography in the three participating centers were performed. Of these, 414 consecutive patients with the diagnosis of coronary aneurysm were observed, representing an estimated incidence of 0.8%. Among these, 256 were considered acute patients (61.8%), the analysis of which will follow. Fig. 1 shows the flow of patients and detailed diagnoses leading up to the index coronary angiography.

    Patient profile, Table 1

    A total of 256 patients, predominantly male (86%) with a mean age of 65.5 years (minimum age 35 and maximum 90, at the time of index catheterization) were included. Cardiovascular risk factors were frequent, including hypertension (65%), dyslipidemia (65%), obesity (25%), diabetes mellitus (28.5%) and a remarkable number of active smokers (67%). 

    Table 1
    General epidemiological profile of acute patients in whom coronary aneurysms are diagnosed in the period between 2002 and 2013. Patients with an acute coronary syndrome were admitted in 2011.
    Clinical features“Acute aneuryms” N = 256“Acute coronary syndrome” N = 500p
    Age 65.5 ± 12.4 years 65.5 ± 13.4 years 0,98
    Sex (male) 221 (86.3%) 401 (80.2%) 0.03
    Arterial hypertension 166 (64.8%) 303 (60.3%) 0.25
    Dyslipidemia 166 (64.8%) 267 (53.4%) 0.00
    Diabetes Mellitus 73 (28.5%) 130 (26.0%) 0.46
    Active smokers 171 (66.8%) 164 (32.8%) 0.00
    Renal insufficiency (CrCl < 30 ml/min) 22 (8.6%) 36 (7.2%) 0.49
    Collagenopathies or other associated conditions 6 (2.3%) NA
    Lupus 1    
    Ankylosing spondylitis 1    
    rheumatoid arthritis 1    
    Polymyalgia rheumatica 2  
    Scapulo-humeral muscular dystrophy 1    
    Intermittent claudication 19 (7.4%) 46 (9.2%) 0.40
    Previous ischemic heart disease 127 (49.6%) 424 (84.2%) 0.00
    LVEF 56.9 ± 12.2% 57.9 ± 12.2% 0.32
    Coronary (severe) stenosis, vessels a 1.76 ± 0.8 1.90 ± 0.9 0.03
    CrCL: creatinine clearance. LVEF: left ventricular ejection fraction.

    a Considering as such, stenosis ≥ 50% for the left main and ≥ 70 for the remaining vessels.

     

    More than 7% of patients experienced peripheral vascular disease of some kind and 16 (6.25%) had described some arterial aneurysm in another location. In addition, almost half of the patients (49.6%) had been previously diagnosed with coronary heart disease and up to 46 of them had experienced a coronary percutaneous intervention (PTCA) previously. In 32 of them (12.5%), treatment focused on the same vessel and location where an aneurysm would be detected later.

    Cardiological and anatomical data

    Fig. 1 shows the diagnoses that led to coronary angiography. In the cohort of acute patients, the most frequent diagnosis was non-ST-elevation acute coronary syndrome (NSTE-ACS) (82.4%). As for the coronary anatomy, the vast majority of patients were found to have right dominance (225), balanced in 14 and left in 17 patients. Severe coronary disease was seen in 240 patients (one vessel in 16, double vessel in 78 and triple vessel in 78). The mean LVEF in the index admission was 57.9 ± 13.7%.

    Regarding the presence of aneurysms, we observed only one in the majority of patients (205; 80.1%), but there were two in 37 patients and three or more in 14 patients. Of these, 4 were considered giant aneurysms. As for the location of the aneurysm, the most commonly affected vessel was the left anterior descending coronary artery (LAD), affected in 122 patients (47.6%), then the RCA (92), the circumflex artery (LCX) or intermediate ramus (80), and finally the left main coronary artery (LMCA) with aneurysms in ten patients (in eight of these it was their only injury at that level). Depending on their structure, aneurysms in more than half of patients (60.2%) were considered as fusiform.

    Hospital stay and treatment

    The median length of stay was five days, with an interquartile range between two and ten.

    •  

      Antithrombotic treatment. Table 2 shows the treatments administered previous to index catheterization during admission and after discharge, during follow-up. 

      Table 2
      Breakdown of antithrombotic treatment prescribed by treating doctors.
      Antithrombotic treatmentN (%) a
      Before admission, (N = 256)
      Aspirin 112 (43.8%)
      Other antiplatelet 24 (9.4%)
      Oral anticoagulation 16 (6.3%)
      During admission, (N = 256)
      Aspirin  
      Second oral antiplatelet 251 (98.0%)
      – Clopidogrel 217 (84.7%)
      – Prasugrel 4 (1.5%)
      – No 35 (13.7%)
      GpIIb/IIIa inhibitors 46 (17.9%)
      Anticoagulation 172 (67.2%)
      Antithrombotics at discharge, (N alive at discharge = 248)
      Aspirin 243 (98.0%)
      Other antiplatelets  
      – Clopidogrel 206 (83.1%)
      – Prasugrel 5 (2.0%)
      Oral anticoagulation 18 (7.3%)
      Triple therapy (ASA + clopidogrel + anticoagulation) 6 (2.4%)
      Duration of dual antiplatelet therapy in follow-up, (N = 248)
      No data 11 (4.4%)
      Never 42 (16.9%) b
      < 3 months 22 (8.9%)
      3–6 months (not included) 8 (3.2%)
      6–12 months (not included) 15 (6.0%)
      12–24 months (not included) 117 (47.1%) c
      24–30 months (not included) 10 (4.0%)
      ≥ 30 months 7 (2.8%)
      Indefinite 16 (6.5%)

      a Some received multiple drugs, so the percentage of cases does not equal 100%. 

      b Of these, 4 patients did not have obstructive coronary disease. 

      c The most frequent duration chosen was 12 months, in 111 cases.

       

    •  

      Treatment, Table 3 . The most frequently treatment selected was percutaneous revascularization. In 171 cases (66.8%) the treated coronary territory was unrelated to the aneurysm. Of these, seven patients received single angioplasty or isolated thromboaspiration, in 34 (13.3%) conventional stent implantation, in 94 a drug-eluting stent implantation and in 37 patients heart surgery. When conventional vs drug-eluting stents were directly analyzed, a greater survival rate was observed in the second group, with similar total follow-up (p = 0.7). 

      Table 3
      Relationship between the most important clinical, anatomical and therapeutic variables with long term death and MACE.
      VariableDeathPMaceP
      Gender   0.91   0.55
      – Male 7 (20.8%)   94 (42.5%)  
      – Female 7 (20.0%)   13 (37.1%)  
      Mean age (± ds)   < 0.001   0.02
        Yes:72.2 ± 12.4   Yes: 67.6 ± 12.9  
        No:63.7 ± 11.8   No: 64.0 ± 11.8  
      Arterial hypertension        
      – Yes 40 (24.8%)   72 (43.4%)  
      – No 13 (14.4%) 0.06 35 (38.9%) 0.48
      Dyslipidemia   0.78   0.06
      – Yes 35 (21.2%)   76 (46.1%)  
      – No 18 (19.8%)   31 (34.1%)  
      Smoker   0.89   0.68
      – Yes 35 (20.5%)   73 (42.7%)  
      – No 18 (21.2%)   34 (40.0%)  
      Family history   0.82   0.80
      – Yes 3 (23.1%)   5 (38.5%)  
      – No 50 (20.6%)   102 (42.0%)  
      Renal insufficiency   0.003   0.08
      – Yes 10 (45.5%)   93 (59.1%)  
      – No 43 (18.4%)   94 (40.2%)  
      Peripheral vascular disease   < 0.001   0.003
      – Yes 10 (52.6%)   14 (73.7%)  
      – No 43 (18.1%)   93 (39.2%)  
      Diabetes mellitus   0.01   0.20
      – Yes 22 (30.1%)   35 (47.9%)  
      – No 31 (16.9%)   72 (39.5%)  
      Aortic disease or aneurysms   0.08   0.005
      – Yes 6 (37.5%)   12 (75.0%)  
      – No 47 (19.6%)   95 (39.6%)  
      Atrial fibrillation   0.45   0.52
      – Yes 4 (28.6%)   7 (50.0%)  
      – No 49 (20.2%)   100 (41.3%)  
      LVEF, mean % (± sd)   < 0.001   0.01
        YES:59.6 ± 11.9   YES:55.5 ± 15.8  
        NO:51.3 ± 17.9   NO:59.7 ± 0.9  
      Previous coronary artery disease   0.83   0.02
      – Yes 9 (19.6%)   26 (56.5%)  
      – No 44 (21.0%)   81 (38.6%)  
      Coronary anatomy DEATH P MACE P
      Coronary stenosis   0.18   0.86
      0 vessel 1 (6.2%)   6 (37.5%)  
      1 vessel 14 (17.9%)   30 (38.5%)  
      2 vessels 15 (19.2%)   34 (43.6%)  
      3 vessels 23 (27.4%)   37 (44.0%)  
      Dominance   0.77   0.81
      – Right 48 (21.3%)   95 (42.2%)  
      – Left 3 (17.6%)   7 (41.2%)  
      – Balanced 2 (14.3%)   5 (35.7%)  
      Aneurysm type   0.97   0.49
      – Fusiform 32 (20.8%)   67 (43.5%)  
      – Sacular 21 (20.6%)   40 (39.2%)  
      Giant   0.14   0.73
      – Yes 2 (50.0%)   2 (50.0%)  
      – No 51 (20.2%)   105 (41.7%)  
      Aneurysm number   0.54   0.29
      – 1 44 (21.5%)   89 (43.0%)  
      – 2 or more 9 (17.6%)   18 (35.3%)  
      Revascularization procedures DEATH P MACE P
      At aneurysm level   0.59   0.58
      – Yes 18 (16.7%)   41 (38.0%)  
      – No 27 (19.3%)   58 (41.4%)  
      Type   0.06   0.52
      – Simple PTCA 0   3 (60.0%)  
      – Conventional stent 7 (35.0%)   10 (50.0%)  
      – Drug-eluting stent 4 (7.8%)   19 (37.3%)  
      – Surgery 7 (21.2)   10 (19.2%)  
      Other vessels   0.71   0.81
      – Yes 31 (18.8%)   65 (39.4)  
      – No 14 (16.9%)   34 (41.0%)  
      Type   0.39   0.58
      – Simple PTCA 1 (14.3%)   4 (57.1%)  
      – Conventional stent 9 (21.0%)   17 (58.0%)  
      – Drug-eluting stent 13 (14.4%)   29 (32.2%)  
      – Surgery 8 (21.6%)   14 (37.8%)  
      Comparison between types of stent (N = 75)   0.004   0.23
      – Drug-eluting stent 6 (11.3%)   21 (39.6%)  
      – Conventional stent 9 (40.9%)   12 (54.5%)  
      Antithrombotics at discharge a DEATH P MACE P
      Dual antiplatelet therapy duration (mean ± sd, months) b   0.017   0.41
      – Yes 7.5 ± 7.9   11.7 ± 16.2  
      – No 13.9 ± 17.4   13.5 ± 16.2  
      12 months or less 27 (17.2%) 0.31 63 (40.5%) 0.71
      > 12 months 4 (10.5%)   14 (36.8%)  
      Oral anticoagulation   0.18   0.34
      – Yes 6 (33.3%)   9 (50.0%)  
      – No 39 (17.1%)   90 (39.5%)  
      ASA at discharge   0.20   0.06
      – Yes 43 (17.7%)   95 (39.1%)  
      – No 2 (40.0%)   4 (80.0%)  

      a It includes living patients at hospital discharge (n = 248). 

      b 195 patients data with specific duration of dual antiplatelet therapy available.

       

     

    Coronary aneurysms were addressed directly in 112 (43.8%) patients. Of these, five received a simple coronary angioplasty, 22 a conventional stent or graft (8.6%), 53 (20.7%) a drug-eluting stent and in 33 (12.9%) cardiac surgery was performed. A patient who underwent cardiac surgery and received no bypass in aneurysmatic artery, had multivessel disease and underwent a single LAD bypass without extracorporeal circulation.

    Monitoring, adverse events and death

    During admission eight patients died (3.1%). The median follow-up reached 52 months, with an interquartile range between 27 and 84 months. During this time, a total of 53 patients died (20.7%). The main causes were cardiac (14), cancer (14), respiratory (7), hemorrhagic (5), multiorgan failure sepsis-(2), stroke (1) and unknown in the rest (7). Fig. 2 shows the Kaplan-Meier survival curves on some relevant clinical and therapeutic variables. 

    Fig. 2
    Chart showing survival rates over 10 years (Kaplan Meier), stratified according to clinically relevant variables. A) In relation to age in quartiles, B) presence or absence of renal failure, C) peripheral vascular disease, D) ejection fraction quartiles, F) depending on the duration (months) of dual antiplatelet therapy (detailing the first 12 months). The curves are similar when assessing only cardiovascular death instead of all cause death (p for comparison = 0.005). G) Use of conventional stents (BMS) vs drug-eluting stents (DES). CrCl: creatinine clearance; LVEF: left ventricular ejection fraction.

     

    In addition, for other adverse events, 45 (17.5%) patients were readmitted for unstable angina, 15 (5.9%) for myocardial reinfarction and 19 (7.4%) for heart failure. Other complications observed during this time were significant bleeding (BARC 2, 3 or 5) in 26 cases (10.1%), arterial thromboembolic events in three (1.8%) and stroke in ten (3.9%) patients. In 107 (41.7%) patients the occurrence of any of the MACE composite endpoint events was observed. Table 3 shows in detail, in univariate exploratory analysis, the relationship between the most important clinical, anatomical and therapeutic variables with the appearance of death and MACE in the long term.Table 4 shows the variables that persist in the multivariate statistical model for death and for the combined event. One can observe the classic prognostic significance of factors such as age, diabetes, ejection fraction, coronary artery disease or peripheral vascular disease. From the therapeutic standpoint we would highlight the use of aspirin and duration of the double antiaggregation. 

    Table 4
    Results of multivariate analysis (backward stepwise, Wald). The models included all variables that in the univariate scan obtained a value of p ≤ 0,10 and refer to the death event and the development of combined MACE event. The model for death included exactly the following variables: hypertension, diabetes mellitus, renal impairment (creatinine clearance calculated by Cockcroft-Gault < 30 ml/min), peripheral vascular disease, arterial aneurysms in territories other than coronary, presence of coronary disease, age (in increasing quartiles), LVEF (in increasing quartiles), duration of dual antiplatelet therapy (in increasing quartiles) and type of treatment (conservative, simple angioplasty, bare-metal stents, drug- eluting stents coronary surgery). The model for MACE was developed with: dyslipidemia, renal impairment (creatinine clearance calculated by Cockcroft-Gault < 30 ml/min), peripheral vascular disease, arterial aneurysms in non-coronary territories, presence of coronary disease, age (in increasing quartiles), LVEF (in increasing quartiles) and ASA use at discharge.
    VariableHazard ratio a95%ICp
    Remaining variables in the multivariate model regarding death
    Peripheral vascular disease 2.64 1.30–5.37 007
    LVEF, increasing quartiles b 0.71 0.54–0.933 014
    Age, increasing quartiles b 1.83 1.34–2.50 000
    Duration of dual antiplatelet therapy in increasing quartiles b 0.73 0.55–0.98 038
     
    Remaining variables in the multivariate model regarding MACE
    Peripheral vascular disease 2.39 1.28–4.25 005
    LVEF, increasing quartiles b 0.84 0.70–1.02 0.08
    Age, increasing quartiles b 1.39 1.15–1.60 001
    Previous coronary artery disease 1.45 0.93–2.24 0.96
    ASA at discharge 0.56 0.32–0.993 0.047
    Bold means the statistical significance is reached (p<0.05).

    a Hazard ratio. 95% CI: confidence interval at 95%.

    b Quartiles LVEF (< 50%; 50 to 59.9%, 60 to 67.9 and > 68%). Quartiles age (< 56; 56–65; 66–75 and > 75). Quartiles dual antiplatelet therapy (< 1 month; 1 to 11.9; 12 and > 12 months).

     

    Follow-up catheterizations

    Iterative coronary angiograms were recorded during follow-up in 94 patients, with a median of 11.6 months (5.8 to 41.8). The reasons included silent- ischemia, angina or NSTEMI (44), control after intervention (27), programmed PTCA (6), chest pain evaluation (6), dyspnea (5), STEMI (4), de novo ventricular dysfunction (1) and noncardiac pre-operative evaluation (1). Conservative management was decided in the vast majority of cases (83%). A growth of aneurysms was observed in five cases and the appearance of new aneurysms in another five patients (three located in the RCA, one in the LAD and one in the LMCA). Also, in two of these patients the previous aneurysm had grown as well.

    Complications derived from the aneurysm were found in four cases (treated with simple PTCA, conventional stent, drug-eluting stent and aortocoronary bypass, respectively), thrombosis in three of them (two in LAD and one in RCA) and one stent restenosis in the aneurysm area (LCX). No ruptures, fistulas or dissections at aneurysms level were observed.

    Control group

    The control cohort was composed of 500 consecutive patients who received at least one coronary angioplasty with stent in the context of an acute coronary syndrome, during 2011. Their cardiovascular risk factors were numerically less prevalent than in cases with aneurysms, Fig. 1 . This difference in cardiovascular profile remained even when comparing only patients with aneurysms in 2011 (the year of the control cohort). Regarding interventionism, from the therapeutic point of view, there was a greater tendency to use conventional stents in the aneurysm group (34.6% vs. 46.1%, p = 0.05), even when compared to patients treated in the same period of time (2011; 32% vs 45.5%). In addition, we performed a propensity score matching obtaining 177 couples, Table 5 . Considering various Cox multivariate models (i.e. Age, hypertension, dyslipemia, diabetes, smoking habit, renal insufficiency, peripheral vessel disease, number of coronary stenosis, LVEF and aneurysms presence) the presence of aneuryms remained an independent risk factor for mortality (Hazard Ratio: 3.1, CI 95% 1.8–5.6; p = 0.000) and MACE (mortality or bleeding or infarction (Hazard Ratio: 2.3, CI 95% 1.4–3.8; p = 0.000). 

    Table 5
    General epidemiological profile for propensity matched groups.
    Clinical features“Acute aneuryms” N = 177“Acute coronary syndrome” N = 177p
    Age 65.0 ± 13.3 years 66.6 ± 12.6 years 0,25
    Sex (male) 142 (80.2%) 140 (79.1%) 0.79
    Arterial hypertension 114 (64.4%) 104 (58.8%) 0.27
    Dyslipidemia 110 (62.1%) 97 (54.8%) 0.16
    Diabetes mellitus 50 (28.2%) 36 (20.3%) 0.08
    Active smokers 92 (52.0%) 89 (50.3%) 0.31
    Renal insufficiency (CrCl < 30 ml/min) 16 (9.0%) 11 (6.2%) 0.31
    Intermittent claudication 15 (8.5%) 18 (10.1%) 0.58
    Previous ischemic heart disease 127 (71.8%) 124 (70.1%) 0.72
    LVEF 57.9 ± 12.2% 57.9 ± 14.2% 0.98

     

    Discussion

    We present the characteristics and long-term evolution, on a patient-level analysis, of one of the longest series of cases with coronary aneurysms reported so far. With limited information up to now, the only data available is based on clinical cases, small series or substudies from other researches, usually post-hoc and non-contemporary, with possibly different profiles and therapeutics  . Moreover, the fact that some articles include coronary ectasia, which may correspond to a different position in the spectrum of the same atherosclerotic disease, contributes to further blurring the few clear concepts that we have nowadays  . For this reason, we strive especially to exclude it in this work  .

    The anatomy is complex to evaluate in patients with aneurysms, also being frequently, patients with coronary lesions in different segments of the coronary tree  . It is remarkable the high load of cardiovascular risk factors  , understood globally, and compared to patients receiving a stent for an acute coronary event, which along with the high frequency of obstructive coronary artery disease and the prognostic influence of certain comorbidities (diabetes, renal failure, peripheral vascular disease …) primarily points to a likely atherosclerotic etiology, as published previously  . Other causes are apparently less frequent, such vasculitis (Kawasaki)  collagenopaties  (Marfan, Ehlers-Danlos syndrome, systemic lupus erythematosus  ), congenital, traumatic and iatrogenic  (usually after implantation of a drug-eluting stent, reaching an incidence of 1.25% in a Spanish case series  ). We only found one (over 414) antecedent of Kawasaki disease and none inside the acute cohort.

    However, we would derive some insights from the data presented in this manuscript. First, the incidence of aneurysms in the catheterization laboratory is uncommon, but not a rare finding (about 0.8% of coronary angiographies). When it presents we have no definitive therapeutic attitude and less in the acute setting, as we have reviewed in this paper. The evolution observed in our patients and their behavior in this series regarding antiplatelet therapy suggests the possibility that these are advanced or aggressive forms of coronary atherosclerosis.

    There have been described multiple percutaneous (simple angioplasty, with stent, stent-grafts exclusion  , coils occlusion  or closure with a Amplatzer in cases of great size  ) or surgical  treatments. Our data suggests acceptable long-term results in terms of percutaneous treatment, now widely available in many centers, and even better results with drug-eluting stents. A remarkably low percentage of drug-eluting stents were observed, which may partly be due to the patient recruitment period, but also operator preferences for various reasons (publications mentioning the appearance of coronary aneurysms in patients treated with drug-eluting stents conventional stents-grafts, etc. …). With the results we present, it seems reasonable, to consider the use of drug-eluting stents, due to possibly improved patient outcomes when treated with these platforms ( Fig. 2 ). Also noteworthy is that in patients who developed complications during follow-up, apparently very few of these were due to the aneurysms themselves.

    Another of the most important aspects, antithrombotic treatment, has almost no data published in the literature . Although the design of this observational study does not clearly allow us to establish recommendations, we can observe a tendency for more intensive treatment and increasing duration of dual antiplatelet therapy to improve survival, which should be taken into account when deciding the medical management of these patients. Despite the absence of certainty, we would view this treatment as a reasonable option if we consider that the existence of a coronary aneurysm could point to an aggressive atherosclerotic process, with same ischemic risk predictors than in regular coronary artery disease. Therefore, while having in mind the current controversy surrounding the duration of dual antiplatelet therapy, we would argue that it is possible that patients with coronary aneurysms could benefit from prolonged treatment, as suggested by studies such as DAPT or PEGASUS. All these findings should be viewed with caution and as hypothesis generating.

    In order to be able to clarify some of the questions that remain regarding patients with coronary aneurysms, we are awaiting the results of the international registry of coronary aneurysms (CAAR; NCT02563626 ), which has recently finished enrolling patients and is expected to become the largest series of patients with coronary aneurysms heretofore.

    Limitations

    We should consider the logistical constraints of a study of this design and of a presumably low-incidence disease. It is possible that some incident cases in the participating hospitals have not been diagnosed and/or have not undergone catheterization, thus underestimating the actual number of acute cardiovascular patients with coronary aneurysms. The incidence calculation was adjusted to the number of coronary angiographies ordered during an acute event, which does not allow extrapolations to the general population. Another limitation is the difficulty in analyzing the various treatments applied, which at all times were determined by the medical team, as well as the comparison group. While these observations give us with an overall idea of the disease, they do not provide information as robust as a clinical trial would do.

    On the basis of the situation under review in this paper, we can only generate hypotheses regarding therapeutics; however, when we consider data from the long-term follow-up, this reveals a reasonably accurate portrayal of the results and the current prognosis of patients who are diagnosed with coronary aneurysm in our environment.

    Conclusions

    The presence of coronary aneurysms in patients undergoing coronary angiography with an acute cardiovascular diagnosis is low. Patients who present them are accompanied by a large burden of atherosclerotic risk factors. In the long term, these patients have a high probability of developing cardiovascular complications, but only a small proportion of these are due to the aneurysms themselves. A more intense and prolonged antithrombotic treatment could result in lower morbidity and mortality rates during follow-up.

    Source of funding

    None.

    Disclosures

    None with regard to this manuscript.

    Author bio

    Cardiovascular Revascularization Medicine, 2018-07-01, Volume 19, Issue 5, Pages 589-596, Copyright © 2017

    Source:

    1. [1]Bourgon A.: Biblioth med. 1812; 37: 183 cited by Scott DH. Aneurysm of the coronary arteries. Am Heart J 1948; 36: pp. 403
    2. [2]Swaye P.S., Fisher L.D., Litwin P., Vignola P.A., Judkins M.P., Kemp H.G., et al: Aneurysmal coronary artery disease. Circulation 1983; 67: pp. 134-138
    3. [3]Syed M., and Lesch M.: Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997; 40: pp. 77-84
    4. [4]Dutary J., Zakhem B., DE Lucas C.B., Paulo M., Gonzalo N., and Alfonso F.: Treatment of a giant coronary artery aneurysm: intravascular ultrasound and optical coherence tomography findings. J Interv Cardiol 2012; 25: pp. 82-85
    5. [5]Maehara A., Mintz G.S., Ahmed J.M., Fuchs S., Castagna M.T., Pichard A.D., et al: An intravascular ultrasound classification of angiographic coronary artery aneurysms. Am J Cardiol 2001; 88: pp. 365-370
    6. [6]Núñez-Gil I.J., Bas M., Fernández-Ortiz A., et al: Long term experience with a novel interventional cardiology network model: learned lessons. J Hosp Admit 2016; vol. 5: pp. 87-94
    7. [7]Li J.J., Li Z., and Li J.: Is any link between inflammation and coronary artery ectasia? Med Hypotheses 2007; 69: pp. 678-683
    8. [8]Diaz-Zamudio M., Bacilio-Perez U., Herrera-Zarza M.C., Meave-González A., Alexanderson-Rosas E., Zambrana-Balta G.F., et al: Coronary artery aneurysms and ectasia: role of coronary CT angiography. Radiographics 2009; 29: pp. 1939-1954
    9. [9]Li J.J., Nie S.P., Qian X.W., Zeng H.S., and Zhang C.Y.: Chronic inflammatory status in patients with coronary artery ectasia. Cytokine 2009; 46: pp. 61-64
    10. [10]Devabhaktuni S., Mercedes A., Diep J., and Ahsan C.: Coronary artery ectasia-a review of current literature. Curr Cardiol Rev 2016; 12: pp. 318-323
    11. [11]Markis J.E., Joffe C.D., Cohn P.F., Feen D.J., and Herman V.: Clinical significance of coronary arterial ectasia. Am J Cardiol 1976; 37: pp. 217-222
    12. [12]Velasco M., Zamorano J.L., Almería C., Ferreiros J., Alfonso F., and Sánchez-Harguindey L.: Multiple coronary aneurysms in a young man. A diagnostic approach via different technics. Rev Esp Cardiol 1999; 52: pp. 55-58
    13. [13]Merchán A., López-Mínguez J.R., Alonso F., Fernández De La Concha J., González R., and Martínez De La Concha L.: Giant left main coronary aneurysm without associated coronary lesions. Rev Esp Cardiol 2002; 55: pp. 308-311
    14. [14]Warisawa T., Naganuma T., Nakamura S., Hartmann M., Stoel M.G., Louwerenburg J.H., et al: How should I treat multiple coronary aneurysms with severe stenoses? EuroIntervention 2015; 11: pp. 843-846
    15. [15]Chiu P., Lynch D., Jahanayar J., Rogers I.S., Tremmel J., and Boyd J.: Bilateral giant coronary artery aneurysms complicated by acute coronary syndrome and cardiogenic shock. Ann Thorac Surg 2016; 101: pp. e95-7
    16. [16]Befeler B., Aranda J.M., Embi A., Mullin F.L., Ei-Sherif N., and Lazzara R.: Coronary artery aneurysms. Study of their etiology, clinical course and effect on left ventricular function and prognosis. Am J Med 1977; 62: pp. 597-607
    17. [17]Letac B., Cazor J.L., Cribier A., Sibile C., and Toussaint C.: Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature. Am Heart J 1980; 99: pp. 694-700
    18. [18]Sadeghi M.M., and Jouzdani S.R.: Giant left anterior descending coronary artery aneurysm in an adult male patient with ST elevation myocardial infarction. J Surg Case Rep 2016; 2016: pp. 1-2
    19. [19]Kato H., Ichinoise E., Yoshioka F., Takechi T., and Matsunaga S.: Fate of coronary aneurysms in Kawasaki disease: serial coronary angiography and long-term follow-up study. Am J Cardiol 1982; 49: pp. 1.758-1.766
    20. [20]Zhao C.N., Du Z.D., and Gao L.L.: Corticosteroid therapy might be associated with the development of coronary aneurysm in children with Kawasaki disease. Chin Med J 2016; 129: pp. 922-928
    21. [21]Sumino H., Kanda T., Sasaki T., Kanazawa N., and Takeuchi H.: Myocardial infarction secondary to coronary aneurysm in systemic lupus erythematosus. An autopsy case. Angiology 1995; 46: pp. 527-530
    22. [22]Levisay J.P., Roth R.M., and Schatz R.A.: Coronary artery aneurysm formation after drug-eluting stent implantation. Cardiovasc Revasc Med 2008; 9: pp. 284-287
    23. [23]Alfonso F., Perez-Vizcayno M.J., Ruiz M., Suarez A., Cazares M., Hernández R., et al: Coronary aneurysms after drug-eluting stent implantation: clinical, angiographic, and intravascular ultrasound findings. J Am Coll Cardiol 2009; 53: pp. 2053-2060
    24. [24]Szalat A., Durst R., Cohen A., and Lotan C.: Use of polytetrafluoroethylene-covered stent for treatment of coronary artery aneurysm. Catheter Cardiovasc Interv 2005; 66: pp. 203-208
    25. [25]Aggarwal V., Mishkel G., and Goswami N.: Percutaneous exclusion of a rapidly enlarging left main coronary artery aneurysm using coils and an Amplatzer™ septal occluder. Catheter Cardiovasc Interv 2016; undefined:
    26. [26]Nakahara Y., Yoshida S., Yamamoto Y., Uemura H., Yamagishi S., Furuhata K., et al: Successful surgical treatment of a giant right coronary artery aneurysm with a patent left internal thoracic artery graft. Gen Thorac Cardiovasc Surg 2017; 65: pp. 285-288
    27. [27]Molina-Martin de Nicolas J., Jurado Roman A., Rubio Alonso B., and Garcia Tejada J.: Recurrent myocardial infarctions due to thrombosis of a coronary aneurysm in neurofibromatosis type 1: is antiplatelet treatment enough? JACC Cardiovasc Interv 2015; 8: pp. e55-7

This site uses cookies. By continuing to browse the site you are agreeing to our use of cookies. Review our Privacy Policy for more details