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A right coronary artery saccular aneurysm leading to an embolic myocardial infarction during diagnostic cardiac catheterization: A case report
Journal of Cardiology Cases 6 (2012) e121–e123
Contents lists available at www.sciencedirect.com
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
A right coronary artery saccular aneurysm leading to an embolic myocardial infarction during diagnostic cardiac catheterization: A case report Ali Buturak (MD) a,∗ , Sinan Dagdelen (MD, PhD) a , Murat Okten (MD) b , Hasan Karabulut (MD, PhD) c Department of Cardiology, School of Medicine, Acıbadem University, Tekin S, No. 8 Acibadem, Kadıköy, I˙ stanbul, Turkey Department of Cardiovascular Surgery, Acıbadem Kadikoy Hospital, I˙ stanbul, Turkey c Department of Cardiovascular Surgery, School of Medicine, Acıbadem University, I˙ stanbul, Turkey a
b
a r t i c l e
i n f o
Article history: Received 17 March 2012 Received in revised form 12 June 2012 Accepted 19 July 2012 Keywords: Coronary artery aneurysm Embolization
a b s t r a c t Coronary artery aneurysms are localized dilatations greater than 1.5 times the diameter of the adjacent segments. These rarely seen abnormalities may lead to serious life-threatening complications such as myocardial infarction, coronary perforation and death. Here, we present a case of periprocedural thromboembolic inferior myocardial infarction arising from a proximal right coronary artery saccular aneurysm during a diagnostic coronary angiography in a stable 70-year-old patient. © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Introduction Coronary aneurysms are observed in 0.15–4.9% of patients undergoing coronary angiography [1]. Thrombosis, distal embolization, and myocardial infarction are reported complications of this rarely seen anomaly [2]. We present a case of inferior myocardial infarction after a diagnostic coronary angiography of a patient with stable angina caused by embolization of a thrombus inside a saccular aneurysm of the proximal right coronary artery. Case report A 70-year-old man was admitted to our hospital with a diagnosis of stable angina pectoris ongoing for the previous two years. He had a history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia. He had been taking aspirin, metformin, gliclazide, perindopril, and atorvastatin since 2005. His blood pressure and heart rate were 160/90 mmHg and 75 beats/min respectively. Heart sounds were normal, and there were no abnormal findings with systemic physical examination. Electrocardiography was normal and transthoracic echocardiography showed left ventricular mild concentric hypertrophy and left ventricular grade 1 diastolic dysfunction. Exercise stress testing with Bruce protocol revealed early ischemic ST segment depressions in V2–V6 persisting several
∗ Corresponding author. Tel.: +90 2165444053; fax: +90 2165444100. E-mail address: [email protected] (A. Buturak).
minutes into the recovery phase. The patient underwent diagnostic coronary angiography after checking biochemical and hematologic laboratory parameters which were all in normal ranges. Coronary angiography via right transradial approach detected multiple critical stenoses in the left anterior descending and well-developed diagonal arteries with a rudimentary left circumflex artery which was totally occluded. Right coronary angiography revealed a critical stenosis with a saccular coronary aneurysm in the proximal portion of the vessel (Fig. 1). Left ventriculography was normal. Elective coronary artery bypass grafting was planned and the patient was removed from the catheter laboratory and taken to the service before discharge. Thirty minutes later, he complained of a resting chest pain with diaphoresis. Electrocardiography displayed maintenance of sinus rhythm with 2–3 mm ST elevations in leads II, III, aVF and reciprocal ST depressions in leads I and aVL. The patient was taken into the catheter laboratory again with the diagnosis of acute inferior myocardial infarction. Initially, in order to exclude aortic dissection, aortography was performed which showed an intact right coronary sinus of valsalva and ascending aorta. Then, right coronary artery (RCA) was canulated with a right judkins 6F guiding catheter (JR4 6F) and an occlusion in the midportion of welldeveloped posterolateral branch with a visible thrombus was seen (Fig. 2); clopidogrel 600 mg and aspirin 300 mg were given orally and intracoronary 5000 units heparin (5000 units heparin were also given at the beginning of diagnostic transradial coronary angiography) were administered additionally. A 0.014 in. Asahi Soft floppy (Abbott Vascular, Santa Clara, CA, USA) guide wire was advanced across the posterolateral branch but guiding catheter support was not enough to reach the lesion with a Pronto V3 manual extraction
1878-5409/$ – see front matter © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jccase.2012.07.008
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A. Buturak et al. / Journal of Cardiology Cases 6 (2012) e121–e123
Fig. 3. Restoration of thrombolysis in myocardial infarction 3 flow in the posterolateral branch of the right coronary artery via balloon angioplasty.
Discussion Fig. 1. Saccular coronary aneurysm (arrow) above the critical stenosis of the proximal right coronary artery.
catheter (Vascular Solutions, Inc., Minneapolis, MN, USA). For this reason, JR4 6F guiding was exchanged with a left amplatz 1 guiding catheter and a second floppy guidewire was passed through the posterior descending artery for better support. But the attempt for aspiration of the thrombus with the extraction catheter failed. Afterwards a 2.0/15 mm Sprinter Legend semicompliant balloon (Medtronic, Minneapolis, MN, USA) was used to reach the posterolateral branch and dilate the thrombotic lesion. Thrombolysis in myocardial infarction 3 flow was restored by the inflation of the balloon at 12 atmospheres successfully (Fig. 3). The patient’s chest pain resolved with resolution of elevated ST segments in electrocardiography. Heparin infusion was started and the patient was consulted by the cardiovascular surgeons for early coronary bypass grafting. Coronary bypass grafting with left internal mammarian artery to distal left anterior descending artery, aortosaphenous grafts to distal RCA, and diagonal artery was performed successfully on the fifth day after admission and seven days later he was discharged from the hospital under dual antiplatelet therapy with aspirin 300 mg and clopidogrel 75 mg once daily.
Fig. 2. Occlusion of the posterolateral branch of the right coronary artery (arrow indicating the thrombus) after diagnostic coronary angiography.
Coronary artery aneurysms are defined as localized coronary artery dilatations greater than 1.5 times the diameter of adjacent coronary segments [3]. This uncommon disorder occurs in 0.15–4.9% of patients undergoing coronary angiography [1]. Most cases have been detected among male patients and RCA is the most frequently affected vessel [4]. Atherosclerosis is the etiological cause in approximately 50% of cases. Kawasaki disease, polyarteritis nodosa, systemic lupus erythematosus, scleroderma, Takayasu arteritis, Ehler–Danlos syndrome, traumatic injury, Behc¸et’s disease, and congenital heart diseases are unusual causes reported [5]. In addition, percutaneous coronary interventions (PCI) including balloon angioplasty, stent implantation, cutting balloon angioplasty, directional coronary atherectomy, and pulsed laser coronary angioplasty have been reported as causes of newly developed coronary artery aneurysms. According to a report by Bal et al., the incidence of coronary aneurysms increases in the patients in whom PCI was complicated with coronary dissections. It is also declared that use of oversized balloons is a predisposing factor to the development of coronary artery aneurysms [6]. Although the exact pathophysiology has not been determined, inflammatory infiltration was shown in histological specimens [7]. Hyperlipidemia, hypertension, and smoking are major risk factors for the disease. Coronary artery aneurysm is usually detected during coronary angiography but multislice computed tomography is an alternative tool for accurate diagnosis. Previous reports have demonstrated potential several complications about coronary aneurysms such as distal embolization of thrombus, myocardial infarction, perforation of the aneurysmal segment, fistulization of coronary aneurysm into one of the cardiac chambers, and sudden cardiac death [3,8,9]. The case we present demonstrates a periprocedural myocardial infarction presumably due to embolization of thrombus from the aneurysm in proximal portion of the RCA. It must be emphasized that coronary angiography may reveal serious complications such as myocardial infarction and intravascular thrombosis in a patient without a coronary aneurysm. Aortography and coronary angiography ruled out a catheter-induced ostial dissection or plaque rupture. And also heparin was administered to the patient just before diagnostic coronary cannulation of the coronary arteries which strongly decreases the risk of catheter-induced thrombosis. The presence of atrial fibrillation, an intracardiac device, and infective endocarditis as secondary causes of coronary thromboembolism were all absent in our case. Contrast media-induced coronary thrombosis may also be excluded because clinical manifestations of clot formation and embolization are uncommon with either ionic or non-ionic contrast agents [10].
A. Buturak et al. / Journal of Cardiology Cases 6 (2012) e121–e123
Although the rupture of minor plaques with or without spasm that can only be diagnosed using intravascular ultrasound (IVUS) may lead to thrombosis, it is also known that coronary aneurysms may contain invisible microthrombi that may induce further platelet aggregation, thrombosis, embolization, and subsequent myocardial infarction [11,12]. Although the first diagnostic angiographic views do not contain a visible thrombus and IVUS was not performed, the absence of the secondary causes indicates the coronary aneurysm as the source of thromboembolism in this case. In our opinion, the aneurysm contains invisible microthrombi which aggregated by the contrast injection in a short time. Treatment of coronary artery aneurysm is still controversial. Surgical intervention, conservative therapy, or percutaneous exclusion of the aneurysmal lumen are suggested options of treatment depending on the size, location of the aneurysm, and the presence of intraluminal thrombus [13–15]. Co-existence of obstructive coronary artery disease is the main determinate of prognosis and appropriate treatment. In isolated cases, medical treatment with antiplatelet and/or anticoagulant agents is the preferred choice. Coronary vasodilators such as nitrates have not been recommended since these agents may provoke ischemia by increasing epicardial dilatation in isolated aneurysms [16]. According to the risk of distal embolization and rupture, more aggressive approaches have been suggested particularly for giant aneurysms or coexisting coronary artery disease. Surgery with ligation of the aneurysm and bypass grafting have been recommended for a long time but there is no agreement on surgical indications except compression of cardiac chambers by giant aneurysms or formation of fistulas with severe shunts [17]. Since the aneurysm was small and no clear indication exists, bypass grafting without ligation of the aneurysm and long-term dual antiplatelet therapy were planned for our case. Percutaneous implantation of covered stents is another interventional approach and especially after the development of polytetrafluoroethylene (PTFE) covered stent technology, various successfully treated cases have been reported [18–20]. Despite the short-term benefit and usefulness of covered stents, there is a lack of data regarding the long-term outcome of patients treated with covered stents. Conclusion Coronary artery aneurysms which may contain thrombus can complicate a diagnostic coronary angiography due to the risk of distal embolization and may lead to myocardial infarction and death.
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This case report presents a periprocedural myocardial infarction due to embolization of a proximal RCA aneurysm thrombus which was successfully treated. References [1] Befeler B, Aranda MJ, Embi A, Mullin FL, El-Sherif N, Lazzara R. Coronary artery aneurysms. Study of their etiology, clinical course and effect on left ventricular function and prognosis. Am J Med 1977;62:597–607. [2] Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997;40:77–84. [3] Hartnell GG, Parnell BM, Pridie RB. Coronary ectasia: its prevalance and clinical significance in 4993 patients. Br Heart J 1985;54:392–5. [4] Ercan E, Tengiz I, Yakut N, Gurbuz A. Large atherosclerotic left main coronary aneurysm: case report and review of literature. Int J Cardiol 2003;88:95–8. [5] Robinson FC. Aneurysms of the coronary arteries. Am Heart J 1985;109: 134–8. [6] Cacucci M, Catanoso A, Valentini P, Rizzini AL, Agricola P, Pedrinazzi C, Ianama G. Right coronary aneurysm: percutaneous treatment with graft-coated stent during the acute phase of myocardial infarction. Int J Cardiol 2009;131:e56–8. [7] Kouzimi J, Izumoto H, Ohsawa A, Ishibashi K, Kawazoe K. Giant coronary artery aneurysm in diagonal artery: report of a case. Kyobu Geka 2002;55:793–5. [8] Biglioli P, Alamanni F, Antona C, Agrifoglio M, Spirito R. Aneurysms of the coronary arteries: one case report. Thorac Cardiovasc Surg 1988;36:239–40. [9] Nazareth J, Weinberg L, Fernandes J, Peyton P, Seevanayagam S. Giant right coronary artery aneurysm presenting with non-ST elevation myocardial infarction and severe mitral regurgitation: a case report. J Med Case Rep 2011;5: 442. [10] Popma JJ. Coronary arteriography. In: Braunwald E, editor. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. Philadelphia: WB Saunders; 2012. p. 411–2. [11] Panduranga P, Riyami AA. Acute intracoronary thrombosis in a normal coronary artery following coronary angiography: thromboaspiration using a guide catheter. Heart Views 2010;11:68–70. [12] Harle T, Reimers J, Hertting K, Kuck KH. Successful trapping of an organized thrombus in a coronary artery aneurysm in myocardial infarction: case report and literature review. Cardiovasc Revasc Med 2008;9:52–5. [13] Everett ME, Holper EM, Lang RM. Giant coronary aneurysm. Am J Geriatr Cardiol 2006;15:394–5. [14] Luz A, Silveira J, Carvalho H, Gomes L. Right coronary artery aneurysm. Int J Cardiol 2007;114:e122–3. [15] Kurtoglu N, Uzunlar B, Yıldırım T, Dindar I. Usefulness of PTFE covered graft stent for the treatment of thrombus containing coronary artery aneurysm. Int J Cardiol 2006;108:424–5. [16] Pahlavan P, Niroomand F. Coronary artery aneurysm: a review. Clin Cardiol 2006;29:439–43. [17] Moreno N, Gonc¸alo L, Castro A, Andrade A, Rodrigues JA, Azevedo J, Ribeiro VG, Pinto P. Left main coronary artery aneurysm. Rev Port Cardiol 2011;30:65–72. [18] Di Mario C, Inglese L, Colombo A. Treatment of a coronary aneurysm with a new polytetrafluoroethylene-coated stent: a case report. Catheter Cardiovasc Interv 1999;46:463–5. [19] Szalat A, Durst R, Cohen A, Lotan C. Use of polytetrafluoroethylene-covered stent for treatment of coronary artery aneurysm. Catheter Cardiovasc Interv 2005;66:203–8. [20] Briguori C, Sarais C, Sivieri G, Takagi T, Di Mario C, Colombo A. Polytetrafluoroethylene-covered stent and coronary artery aneurysms. Catheter Cardiovasc Interv 2002;55:326–30.
Contents lists available at www.sciencedirect.com
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
A right coronary artery saccular aneurysm leading to an embolic myocardial infarction during diagnostic cardiac catheterization: A case report Ali Buturak (MD) a,∗ , Sinan Dagdelen (MD, PhD) a , Murat Okten (MD) b , Hasan Karabulut (MD, PhD) c Department of Cardiology, School of Medicine, Acıbadem University, Tekin S, No. 8 Acibadem, Kadıköy, I˙ stanbul, Turkey Department of Cardiovascular Surgery, Acıbadem Kadikoy Hospital, I˙ stanbul, Turkey c Department of Cardiovascular Surgery, School of Medicine, Acıbadem University, I˙ stanbul, Turkey a
b
a r t i c l e
i n f o
Article history: Received 17 March 2012 Received in revised form 12 June 2012 Accepted 19 July 2012 Keywords: Coronary artery aneurysm Embolization
a b s t r a c t Coronary artery aneurysms are localized dilatations greater than 1.5 times the diameter of the adjacent segments. These rarely seen abnormalities may lead to serious life-threatening complications such as myocardial infarction, coronary perforation and death. Here, we present a case of periprocedural thromboembolic inferior myocardial infarction arising from a proximal right coronary artery saccular aneurysm during a diagnostic coronary angiography in a stable 70-year-old patient. © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Introduction Coronary aneurysms are observed in 0.15–4.9% of patients undergoing coronary angiography [1]. Thrombosis, distal embolization, and myocardial infarction are reported complications of this rarely seen anomaly [2]. We present a case of inferior myocardial infarction after a diagnostic coronary angiography of a patient with stable angina caused by embolization of a thrombus inside a saccular aneurysm of the proximal right coronary artery. Case report A 70-year-old man was admitted to our hospital with a diagnosis of stable angina pectoris ongoing for the previous two years. He had a history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia. He had been taking aspirin, metformin, gliclazide, perindopril, and atorvastatin since 2005. His blood pressure and heart rate were 160/90 mmHg and 75 beats/min respectively. Heart sounds were normal, and there were no abnormal findings with systemic physical examination. Electrocardiography was normal and transthoracic echocardiography showed left ventricular mild concentric hypertrophy and left ventricular grade 1 diastolic dysfunction. Exercise stress testing with Bruce protocol revealed early ischemic ST segment depressions in V2–V6 persisting several
∗ Corresponding author. Tel.: +90 2165444053; fax: +90 2165444100. E-mail address: [email protected] (A. Buturak).
minutes into the recovery phase. The patient underwent diagnostic coronary angiography after checking biochemical and hematologic laboratory parameters which were all in normal ranges. Coronary angiography via right transradial approach detected multiple critical stenoses in the left anterior descending and well-developed diagonal arteries with a rudimentary left circumflex artery which was totally occluded. Right coronary angiography revealed a critical stenosis with a saccular coronary aneurysm in the proximal portion of the vessel (Fig. 1). Left ventriculography was normal. Elective coronary artery bypass grafting was planned and the patient was removed from the catheter laboratory and taken to the service before discharge. Thirty minutes later, he complained of a resting chest pain with diaphoresis. Electrocardiography displayed maintenance of sinus rhythm with 2–3 mm ST elevations in leads II, III, aVF and reciprocal ST depressions in leads I and aVL. The patient was taken into the catheter laboratory again with the diagnosis of acute inferior myocardial infarction. Initially, in order to exclude aortic dissection, aortography was performed which showed an intact right coronary sinus of valsalva and ascending aorta. Then, right coronary artery (RCA) was canulated with a right judkins 6F guiding catheter (JR4 6F) and an occlusion in the midportion of welldeveloped posterolateral branch with a visible thrombus was seen (Fig. 2); clopidogrel 600 mg and aspirin 300 mg were given orally and intracoronary 5000 units heparin (5000 units heparin were also given at the beginning of diagnostic transradial coronary angiography) were administered additionally. A 0.014 in. Asahi Soft floppy (Abbott Vascular, Santa Clara, CA, USA) guide wire was advanced across the posterolateral branch but guiding catheter support was not enough to reach the lesion with a Pronto V3 manual extraction
1878-5409/$ – see front matter © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jccase.2012.07.008
e122
A. Buturak et al. / Journal of Cardiology Cases 6 (2012) e121–e123
Fig. 3. Restoration of thrombolysis in myocardial infarction 3 flow in the posterolateral branch of the right coronary artery via balloon angioplasty.
Discussion Fig. 1. Saccular coronary aneurysm (arrow) above the critical stenosis of the proximal right coronary artery.
catheter (Vascular Solutions, Inc., Minneapolis, MN, USA). For this reason, JR4 6F guiding was exchanged with a left amplatz 1 guiding catheter and a second floppy guidewire was passed through the posterior descending artery for better support. But the attempt for aspiration of the thrombus with the extraction catheter failed. Afterwards a 2.0/15 mm Sprinter Legend semicompliant balloon (Medtronic, Minneapolis, MN, USA) was used to reach the posterolateral branch and dilate the thrombotic lesion. Thrombolysis in myocardial infarction 3 flow was restored by the inflation of the balloon at 12 atmospheres successfully (Fig. 3). The patient’s chest pain resolved with resolution of elevated ST segments in electrocardiography. Heparin infusion was started and the patient was consulted by the cardiovascular surgeons for early coronary bypass grafting. Coronary bypass grafting with left internal mammarian artery to distal left anterior descending artery, aortosaphenous grafts to distal RCA, and diagonal artery was performed successfully on the fifth day after admission and seven days later he was discharged from the hospital under dual antiplatelet therapy with aspirin 300 mg and clopidogrel 75 mg once daily.
Fig. 2. Occlusion of the posterolateral branch of the right coronary artery (arrow indicating the thrombus) after diagnostic coronary angiography.
Coronary artery aneurysms are defined as localized coronary artery dilatations greater than 1.5 times the diameter of adjacent coronary segments [3]. This uncommon disorder occurs in 0.15–4.9% of patients undergoing coronary angiography [1]. Most cases have been detected among male patients and RCA is the most frequently affected vessel [4]. Atherosclerosis is the etiological cause in approximately 50% of cases. Kawasaki disease, polyarteritis nodosa, systemic lupus erythematosus, scleroderma, Takayasu arteritis, Ehler–Danlos syndrome, traumatic injury, Behc¸et’s disease, and congenital heart diseases are unusual causes reported [5]. In addition, percutaneous coronary interventions (PCI) including balloon angioplasty, stent implantation, cutting balloon angioplasty, directional coronary atherectomy, and pulsed laser coronary angioplasty have been reported as causes of newly developed coronary artery aneurysms. According to a report by Bal et al., the incidence of coronary aneurysms increases in the patients in whom PCI was complicated with coronary dissections. It is also declared that use of oversized balloons is a predisposing factor to the development of coronary artery aneurysms [6]. Although the exact pathophysiology has not been determined, inflammatory infiltration was shown in histological specimens [7]. Hyperlipidemia, hypertension, and smoking are major risk factors for the disease. Coronary artery aneurysm is usually detected during coronary angiography but multislice computed tomography is an alternative tool for accurate diagnosis. Previous reports have demonstrated potential several complications about coronary aneurysms such as distal embolization of thrombus, myocardial infarction, perforation of the aneurysmal segment, fistulization of coronary aneurysm into one of the cardiac chambers, and sudden cardiac death [3,8,9]. The case we present demonstrates a periprocedural myocardial infarction presumably due to embolization of thrombus from the aneurysm in proximal portion of the RCA. It must be emphasized that coronary angiography may reveal serious complications such as myocardial infarction and intravascular thrombosis in a patient without a coronary aneurysm. Aortography and coronary angiography ruled out a catheter-induced ostial dissection or plaque rupture. And also heparin was administered to the patient just before diagnostic coronary cannulation of the coronary arteries which strongly decreases the risk of catheter-induced thrombosis. The presence of atrial fibrillation, an intracardiac device, and infective endocarditis as secondary causes of coronary thromboembolism were all absent in our case. Contrast media-induced coronary thrombosis may also be excluded because clinical manifestations of clot formation and embolization are uncommon with either ionic or non-ionic contrast agents [10].
A. Buturak et al. / Journal of Cardiology Cases 6 (2012) e121–e123
Although the rupture of minor plaques with or without spasm that can only be diagnosed using intravascular ultrasound (IVUS) may lead to thrombosis, it is also known that coronary aneurysms may contain invisible microthrombi that may induce further platelet aggregation, thrombosis, embolization, and subsequent myocardial infarction [11,12]. Although the first diagnostic angiographic views do not contain a visible thrombus and IVUS was not performed, the absence of the secondary causes indicates the coronary aneurysm as the source of thromboembolism in this case. In our opinion, the aneurysm contains invisible microthrombi which aggregated by the contrast injection in a short time. Treatment of coronary artery aneurysm is still controversial. Surgical intervention, conservative therapy, or percutaneous exclusion of the aneurysmal lumen are suggested options of treatment depending on the size, location of the aneurysm, and the presence of intraluminal thrombus [13–15]. Co-existence of obstructive coronary artery disease is the main determinate of prognosis and appropriate treatment. In isolated cases, medical treatment with antiplatelet and/or anticoagulant agents is the preferred choice. Coronary vasodilators such as nitrates have not been recommended since these agents may provoke ischemia by increasing epicardial dilatation in isolated aneurysms [16]. According to the risk of distal embolization and rupture, more aggressive approaches have been suggested particularly for giant aneurysms or coexisting coronary artery disease. Surgery with ligation of the aneurysm and bypass grafting have been recommended for a long time but there is no agreement on surgical indications except compression of cardiac chambers by giant aneurysms or formation of fistulas with severe shunts [17]. Since the aneurysm was small and no clear indication exists, bypass grafting without ligation of the aneurysm and long-term dual antiplatelet therapy were planned for our case. Percutaneous implantation of covered stents is another interventional approach and especially after the development of polytetrafluoroethylene (PTFE) covered stent technology, various successfully treated cases have been reported [18–20]. Despite the short-term benefit and usefulness of covered stents, there is a lack of data regarding the long-term outcome of patients treated with covered stents. Conclusion Coronary artery aneurysms which may contain thrombus can complicate a diagnostic coronary angiography due to the risk of distal embolization and may lead to myocardial infarction and death.
e123
This case report presents a periprocedural myocardial infarction due to embolization of a proximal RCA aneurysm thrombus which was successfully treated. References [1] Befeler B, Aranda MJ, Embi A, Mullin FL, El-Sherif N, Lazzara R. Coronary artery aneurysms. Study of their etiology, clinical course and effect on left ventricular function and prognosis. Am J Med 1977;62:597–607. [2] Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997;40:77–84. [3] Hartnell GG, Parnell BM, Pridie RB. Coronary ectasia: its prevalance and clinical significance in 4993 patients. Br Heart J 1985;54:392–5. [4] Ercan E, Tengiz I, Yakut N, Gurbuz A. Large atherosclerotic left main coronary aneurysm: case report and review of literature. Int J Cardiol 2003;88:95–8. [5] Robinson FC. Aneurysms of the coronary arteries. Am Heart J 1985;109: 134–8. [6] Cacucci M, Catanoso A, Valentini P, Rizzini AL, Agricola P, Pedrinazzi C, Ianama G. Right coronary aneurysm: percutaneous treatment with graft-coated stent during the acute phase of myocardial infarction. Int J Cardiol 2009;131:e56–8. [7] Kouzimi J, Izumoto H, Ohsawa A, Ishibashi K, Kawazoe K. Giant coronary artery aneurysm in diagonal artery: report of a case. Kyobu Geka 2002;55:793–5. [8] Biglioli P, Alamanni F, Antona C, Agrifoglio M, Spirito R. Aneurysms of the coronary arteries: one case report. Thorac Cardiovasc Surg 1988;36:239–40. [9] Nazareth J, Weinberg L, Fernandes J, Peyton P, Seevanayagam S. Giant right coronary artery aneurysm presenting with non-ST elevation myocardial infarction and severe mitral regurgitation: a case report. J Med Case Rep 2011;5: 442. [10] Popma JJ. Coronary arteriography. In: Braunwald E, editor. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. Philadelphia: WB Saunders; 2012. p. 411–2. [11] Panduranga P, Riyami AA. Acute intracoronary thrombosis in a normal coronary artery following coronary angiography: thromboaspiration using a guide catheter. Heart Views 2010;11:68–70. [12] Harle T, Reimers J, Hertting K, Kuck KH. Successful trapping of an organized thrombus in a coronary artery aneurysm in myocardial infarction: case report and literature review. Cardiovasc Revasc Med 2008;9:52–5. [13] Everett ME, Holper EM, Lang RM. Giant coronary aneurysm. Am J Geriatr Cardiol 2006;15:394–5. [14] Luz A, Silveira J, Carvalho H, Gomes L. Right coronary artery aneurysm. Int J Cardiol 2007;114:e122–3. [15] Kurtoglu N, Uzunlar B, Yıldırım T, Dindar I. Usefulness of PTFE covered graft stent for the treatment of thrombus containing coronary artery aneurysm. Int J Cardiol 2006;108:424–5. [16] Pahlavan P, Niroomand F. Coronary artery aneurysm: a review. Clin Cardiol 2006;29:439–43. [17] Moreno N, Gonc¸alo L, Castro A, Andrade A, Rodrigues JA, Azevedo J, Ribeiro VG, Pinto P. Left main coronary artery aneurysm. Rev Port Cardiol 2011;30:65–72. [18] Di Mario C, Inglese L, Colombo A. Treatment of a coronary aneurysm with a new polytetrafluoroethylene-coated stent: a case report. Catheter Cardiovasc Interv 1999;46:463–5. [19] Szalat A, Durst R, Cohen A, Lotan C. Use of polytetrafluoroethylene-covered stent for treatment of coronary artery aneurysm. Catheter Cardiovasc Interv 2005;66:203–8. [20] Briguori C, Sarais C, Sivieri G, Takagi T, Di Mario C, Colombo A. Polytetrafluoroethylene-covered stent and coronary artery aneurysms. Catheter Cardiovasc Interv 2002;55:326–30.