Abstract
Coronary artery aneurysms are increasingly identified through coronary angiography. To date, no consensus exists regarding the optimal management strategy. Treatment options include surgical intervention, stent placement, or medical therapy. We present a case demonstrating the successful use of a balloon-assisted technique to precisely locate the aneurysm origin and achieve effective exclusion with a covered stent, highlighting its potential as a novel therapeutic approach.
Keywords: Coronary artery aneurysm, balloon-assisted technique, covered stent, interventional cardiology, saccular aneurysm
A coronary artery aneurysm is defined as a localized enlargement of a coronary artery exceeding 1.5 times the diameter of the reference vessel. It is classified as a saccular aneurysm when the transverse diameter surpasses the longitudinal length.[1] Clinical presentation can vary, ranging from asymptomatic findings to acute coronary syndromes.[1] Although imaging modalities such as computed tomography, coronary angiography (CAG), and intravascular ultrasound (IVUS) can delineate aneurysm anatomy, precise localization of the aneurysm origin may remain challenging, particularly in complex cases.
Balloon-assisted localization is a rarely described technique in this context but offers a practical solution when advanced imaging tools are unavailable or inconclusive. By accurately identifying the aneurysm neck, this method facilitates appropriate percutaneous treatment planning. In this report, we present a patient with a giant saccular aneurysm and myocardial ischemia, in whom the aneurysm origin was successfully identified using balloon-assisted localization, followed by percutaneous covered stent implantation (Papyrus, Biotronik).
Case Report
A 56-year-old male presented to the cardiology outpatient clinic with exertional dyspnea. His medical history was significant for diabetes mellitus, hypertension, and a history of smoking. Electrocardiography revealed sinus rhythm without ischemic changes. Echocardiography demonstrated a left ventricular ejection fraction of 40% and hypokinesia of the anterior segments.
CAG revealed a 14×10 mm giant saccular aneurysm at the level of the diagonal artery and non-critical stenosis in the mid left anterior descending artery (Video 1). The aneurysm was planned for closure using a covered stent.
A non-compliant balloon measuring 3.5×10 mm was inflated, allowing identification of the aneurysm origin at the level of diagonal 1 (Video 2). A 3.0×20 mm covered stent was deployed at 20 atmospheres (atm), positioned proximally to the diagonal artery. Control angiography showed persistent blood flow within the aneurysm. Subsequently, a 3.5×10 mm non-compliant balloon was inflated at 24 atm for one minute. Follow-up angiography demonstrated complete exclusion of the aneurysm, with no residual contrast filling within the aneurysmal sac, indicating successful closure (Video 3).
The patient was transferred to the coronary intensive care unit for monitoring. After 72 hours of observation, his treatment plan was adjusted, and he was discharged in stable condition.
Discussion
The increased use of CAG has led to a higher detection rate of coronary aneurysms. An aneurysm is classified as giant when it exceeds four times the diameter of the reference vessel.[1]
The optimal management strategy for these patients remains uncertain due to the lack of randomized trials. Surgical intervention is generally considered for patients with giant aneurysms or those at risk of significant side branch compromise.[1] According to Lunardi et al.,[2] a side branch <2 mm in diameter with a short course can be considered non-significant. In cases with favorable anatomical features, percutaneous coronary intervention may be a viable alternative.[1] In our case, balloon inflation confirmed that the lesion originated from a diagonal branch measuring <2 mm with a short course; thus, it was considered negligible. Percutaneous closure with a covered stent was therefore selected as the optimal treatment strategy.
While CAG remains the standard imaging modality for aneurysm detection, intravascular imaging and computed tomography angiography (CTA) can provide additional value in complex cases by defining vessel diameter and precisely localizing the aneurysm origin.[1] When these modalities are unavailable, balloon-assisted localization offers a practical alternative. In our patient, this technique enabled accurate assessment and facilitated successful percutaneous closure with a covered stent.
A French multicenter study reported an approximate 9% rate of in-stent restenosis and target lesion revascularization at 2-year follow-up in patients treated with covered stents, supporting the mid-term safety and efficacy of this approach.[3]
Although similar aneurysm cases have been reported, our approach differs from previous studies. Holvoet et al.[4] treated a saccular aneurysm in the left main coronary artery under IVUS guidance, while Barioli et al.[5] utilized a self-expanding micro-mesh nitinol carotid stent with IVUS to ensure proper stent apposition. Unlike these studies, our approach relied solely on balloon-assisted localization in the absence of advanced imaging, demonstrating its feasibility in resource-limited settings. This method enabled precise aneurysm localization followed by successful percutaneous covered stent implantation, offering a minimally invasive alternative when intravascular imaging is unavailable due to cost or healthcare system limitations.
Some patients with coronary aneurysms may present with severe complications, such as cardiac tamponade, which may necessitate emergency surgical intervention. In certain cases, a ruptured coronary aneurysm may only be diagnosed intraoperatively, underscoring the need for early surgical consideration in select patients.[6] These reports highlight that percutaneous covered stent treatment can serve as a safe and minimally invasive alternative to surgery in appropriate cases.
Our technique has several limitations. Advanced imaging methods (e.g., IVUS, CTA) provide detailed anatomical information and facilitate optimal stent apposition. The absence of intravascular imaging in this case may affect long-term outcomes. Additionally, the lack of long-term follow-up imaging limits assessment of sustained stent patency and aneurysm exclusion. Future follow-up plans include scheduled non-invasive imaging at 6-12 months and beyond to monitor for potential restenosis or aneurysm recurrence, providing a more comprehensive evaluation of procedural efficacy and safety.
This case emphasizes the utility of balloon-assisted localization in the management of coronary aneurysms when advanced imaging is not feasible. In anatomically complex cases, this technique can facilitate precise stent placement and potentially avoid unnecessary surgical intervention.
Ethics
Informed Consent: Written informed consent for the publication of all clinical data and images related to this case was obtained from the patient.
Supplementary Materials
Acknowledgments
For transparency, the authors note that an artificial intelligence-assisted language model (ChatGPT, OpenAI) was utilized to support text editing and language correction. This assistance was limited to linguistic refinement; all scientific content, critical analysis, and final editorial decisions were made exclusively by the authors.
Footnotes
Authorship Contributions: Surgical and Medical Practices: R.A., M.R.E.; Concept: R.A., M.R.E., A.D., G.Ç., Ş.A.; Design: R.A., M.R.E., G.Ç., Ş.A.; Data Collection or Processing: R.A., A.D.; Analysis or Interpretation: R.A., G.Ç., Ş.A.; Literature Search: R.A., M.R.E., A.D.; Writing: R.A., Ş.A.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
References
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