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.
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.