Abstract
A coronary artery aneurysm (CAA) is an uncommon clinical finding with an incidence of <5% in adults. The presence of a large intracoronary thrombus within an aneurysmal coronary artery and normal coronary flow is usually a very challenging case scenario. Here, we present a case of a patient presenting with typical chest pain symptoms, high-risk findings on a pharmacological nuclear stress test and coronary angiogram showing severe multivessel coronary artery disease, including a large aneurysmal segment within the proximal left anterior descending artery with a large thrombus that did not affect intracoronary flow. Today, there are no published guidelines for the management of CAA with a normal intracoronary flow. The approach used in this case was initial antithrombotic therapy followed by a successful staged percutaneous coronary intervention. Here, we present a case supporting the use of combined intravenous anticoagulant and antiplatelet therapy for 48 hours, followed by successful percutaneous intervention guided by intravascular ultrasound.
Keywords: cardiovascular medicine, interventional cardiology, pericardial disease
Background
An aneurysmal dilation of the coronary arteries was originally described in 1761 by Giovanni Morgagni as an ‘aneurysm the size of a walnut’ above the semilunar valves,1 but it was not until 1812 that the term coronary artery aneurysm (CAA) was used by Charles Bougon.2 Aneurysmal coronary artery disease (ACAD) is a term that encompasses both CAA and coronary artery ectasia (CAE). Arbitrary criteria have been published to classify these two. CAA is defined as focal irreversible dilation of the lumen of at least 1.5 times the adjacent normal coronary segment, whereas CAE is used to describe the diffuse dilation of a segment involving at least ≥50% of the length of the artery.3 4 The observed prevalence of ACAD in patients undergoing coronary angiography is up to 5%.4 Left anterior descending (LAD) artery aneurysmal involvement is exceedingly rarely present in approximately 17% of ACAD.5 The lack of an international societal consensus concerning the optimal management of ACAD poses a clinical dilemma to the clinician.4
Currently, there are no guidelines for the optimal management strategy of a large intracoronary thrombus in an aneurysmal segment with normal flow. The aforementioned characteristics portray a very challenging clinical scenario.
Case presentation
A 72-year-old man presented with episodes of chest pain over a 1-month period. The pain was described as mild to moderate, midsternal pressure, worst with physical exertion and that resolved with rest. Medical history includes prior inferior wall ST elevation myocardial infarction with percutaneous coronary intervention (PCI) of right coronary artery with a drug-eluting stent (DES) 2 years prior and diabetes mellitus type 2. The vital signs were within normal limits, and physical examination was unremarkable.
Investigations
Initial 12-lead ECG revealed sinus tachycardia with no ST segment deviation. Complete blood count, complete metabolic panel, lipid panel and coagulation profile results were within normal limits. Cardiac enzymes were negative. Chest X-ray was unremarkable.
A regadenoson nuclear stress test was performed for further risk stratification. Immediately after pharmacological stress, he developed severe chest pain associated with diffuse ST segment depression in the precordial leads and concomitant ST segment elevation in aVR concerning for severe left main or multivessel CAD. The perfusion images showed ischaemia in the distribution of the circumflex coronary artery. The patient was sent for coronary angiography, which then revealed severe multivessel CAD including a large intracoronary thrombus in an aneurysmal segment of the proximal LAD artery (figure 1, see video 1). There was severe diffuse in-stent restenosis of the proximal to mid-right coronary artery; severe diffuse disease of the distal right coronary artery, right posterior descending artery and right posterior lateral artery (figure 2); and severe subtotal stenosis of two obtuse marginal branches of the left circumflex (figure 3) (see videos 2 and 3).
Figure 1.
Left coronary angiogram showing an aneurysmal proximal left anterior descending coronary artery with a large intra-aneurysmal thrombus (yellow arrow).
Video 1.
Figure 2.
Coronary angiogram of the right coronary artery with severe diffuse disease in the proximal segment (yellow arrow) and mid segment (red arrow), and in the right posterior descending and posterior lateral branches (green arrows).
Figure 3.
Left coronary angiogram demonstrating severe, subtotal stenoses in two obtuse marginal branches of the left circumflex (yellow arrow and red arrow).
Video 2.
Video 3.
Treatment
During coronary angiography, the patient had ischaemic ST changes and developed severe chest pain symptoms. The patient remained haemodynamically stable and flow into the distal LAD coronary was normal despite the presence of a large thrombus. An intra-aortic balloon pump was inserted with immediate resolution of symptoms and ST changes. Further evaluation of coronary anatomy was performed with intravascular ultrasound (IVUS). In view of severe multivessel CAD with proximal LAD involvement and history of diabetes mellitus, the patient was taken off the catheterisation laboratory table for a heart team discussion for possible coronary artery bypass graft surgery.
After a multidisciplinary team discussion, the decision was made to keep the patient on a therapeutic intravenous heparin and eptifibatide infusion for 48 hours, followed by repeat coronary angiography and possible percutaneous intervention of the proximal LAD. Repeat angiogram showed complete resolution of the thrombus with evidence of an ulcerated plaque that was likely the culprit (figure 4, see video 4). This lesion underwent successful PCI with a 5.0 mm DES, followed by post-dilation with a 6.0 mm non-compliant balloon (figure 5 and video 5). IVUS was performed before and after intervention (figure 6) (see video 6).
Figure 4.
Left coronary angiogram after therapeutic infusion of intravenous heparin and eptifibatide demonstrating complete resolution of the thrombus in the proximal left anterior descending coronary artery, but with evidence of an ulcerated plaque (yellow arrow).
Video 4.
Figure 5.
Left coronary angiogram after successful percutaneous coronary intervention of the proximal left anterior descending coronary artery with a drug-eluting stent.
Video 5.
Figure 6.
Intravascular ultrasound demonstrating the left coronary artery thrombus burden in the aneurysmal segment.
Video 6.
Outcome and follow-up
After coronary intervention, the pharmacological treatment consisted of dual antiplatelet therapy with aspirin plus clopidogrel, bisoprolol and atorvastatin in addition to insulin therapy. Complete resolution of anginal symptoms was successfully achieved after intervention. He was discharged 24 hours after procedure with close follow-up as outpatient. The patient had complete resolution of symptoms with a return of usual activities. His residual severe CAD of the right coronary artery and circumflex were left for medical management.
Discussion
Coronary angiography remains the gold standard for the evaluation of CAAs. ACAD involving the LAD artery is very uncommon.3 A CAA with a large thrombus with normal distal flow represents a unique clinical challenge. Multiple approaches have been described. This includes PCI with balloon angioplasty and/or thrombectomy with stent placement, coronary artery bypass graft (CABG) with aneurysmal ligation or medical therapy alone. Medical therapy is based on the prevention of thromboembolic complications using antiplatelet and anticoagulant medications.3 4 Surgical management may be indicated in symptomatic patients with multivessel CAD, complex coronary anatomy, diabetes mellitus and/or severely depressed left ventricular systolic function.5 Other authors advocate for a surgical approach, but CABG in the absence of a flow-limiting stenosis raises concerns due to the risk of failed internal mammary artery maturation or long-term patency of a venous bypass graft after thrombus resolution in the native artery with normal flow. PCI is the preferred revascularisation strategy when the coronary anatomy is suitable, surgery is not indicated and if the patient can tolerate antiplatelet therapy. A major concern for PCI on an aneurysmal coronary is optimal stent apposition. If there is a large thrombus burden, distal embolisation is also possible.6 Antithrombotic therapy alone can reduce the thrombotic burden; however, their effectiveness is not always optimal.7 There is no controversy on the management; there are just several options. Each case should be individualised to decide which approach is best.8
Learning points.
Coronary angiography remains the gold standard for the evaluation of coronary artery aneurysms.
If there is a large thrombus burden, initial antithrombotic therapy followed by a staged percutaneous procedure is safe and even more helpful as long as there is normal distal flow, symptoms are controlled and there is haemodynamic stability.
Intravascular ultrasound helped assess the thrombus burden and guide percutaneous coronary intervention.
Footnotes
Contributors: AH, CFMM, JFTM and AB contributed to all the parts of the manuscript, including planning, design, data collection, analysis of data, drafting and revision.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Consent obtained directly from patient(s).
References
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