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Coronary Artery Aneurysms: Outcomes Following Medical, Percutaneous Interventional and Surgical Management

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Coronary Artery Aneurysms: Outcomes Following Medical, Percutaneous Interventional and Surgical Management Open access Coronary artery disease Open Heart: first published as 10.1136/openhrt-2020-001440 on 10 February 2021. Downloaded from Coronary artery aneurysms: outcomes following medical, percutaneous interventional and surgical management Shameer Khubber ,1 Rajdeep Chana,1 Chandramohan Meenakshisundaram,1 Kamal Dhaliwal,1 Mohomed Gad,1 Manpreet Kaur,1 Kinjal Banerjee,2 Beni Rai Verma,1 Shashank Shekhar,1 Muhummad Zia Khan,3 Muhammad Shahzeb Khan ,4 Safi Khan,5 Yasser Sammour,1 Rayji Tsutsui,1 Rishi Puri,1 Ankur Kalra,6 Faisal G Bakaeen,1 Conrad Simpfendorfer,1 Stephen Ellis,1 Douglas Johnston,1 Gosta Pettersson,7 Samir Kapadia1 To cite: Khubber S, Chana R, ABSTRACT Key questions Meenakshisundaram C, et al. Background Coronary artery aneurysms (CAAs) are Coronary artery aneurysms: increasingly diagnosed on coronary angiography; however, outcomes following medical, What is already known about this subject? controversies persist regarding their optimal management. percutaneous interventional and ► Coronary artery aneurysms (CAAs) are increasingly surgical management. Open In the present study, we analysed the long- term being diagnosed on coronary angiography. However, Heart 2021;8:e001440. outcomes of patients with CAAs following three different there is paucity of data regarding the long- term doi:10.1136/ management strategies. outcomes of different management strategies in openhrt-2020-001440 Methods We performed a retrospective review of patient patients with CAA. records with documented CAA diagnosis between 2000 What does this study add? Received 7 September 2020 and 2005. Patients were divided into three groups: Our study analysed the long-term MACCE outcomes Revised 23 December 2020 medical management versus percutaneous coronary ► Accepted 2 January 2021 intervention (PCI) versus coronary artery bypass grafting of patients with CAAs who underwent medical (CABG). We analysed the rate of major cardiovascular management versus percutaneous and surgical and cerebrovascular events (MACCEs) over a period of 10 interventions. years. How might this impact on clinical practice? Results We identified 458 patients with CAAs (mean http://openheart.bmj.com/ ► Our results will inform clinical decisions regarding © Author(s) (or their age 78±10.5 years, 74.5% men) who received medical employer(s)) 2021. Re- use the selection of management strategies for patients permitted under CC BY- NC. No therapy (N=230) or underwent PCI (N=52) or CABG with CAA and the role of antiplatelet/anticoagulant commercial re- use. See rights (N=176). The incidence of CAAs was 0.7% of the total therapy in this patient cohort. and permissions. Published catheterisation reports. The left anterior descending by BMJ. was the most common coronary artery involved (38%). 1Heart and Vascular Institute, The median follow- up time was 62 months. The total Cleveland Clinic, Cleveland, number of MACCE during follow- up was 155 (33.8%); INTRODUCTION Ohio, USA 91 (39.6%) in the medical management group vs 46 The incidence of coronary artery aneurysms 2Department of Internal 1 (26.1%) in the CABG group vs 18 (34.6%) in the PCI group (CAAs) varies from 0.3% to 5.3%. In most on September 27, 2021 by guest. Protected copyright. Medicine, Geisinger Medical cases, CAAs are asymptomatic. However, when Center, Danville, Pennsylvania, (p=0.02). Kaplan- Meier survival analysis showed that USA CABG was associated with better MACCE- free survival symptomatic, the clinical presentation varies 3Department of Medicine, West (p log- rank=0.03) than medical management. These and is typically dependent on the underlying Virginia University, Morgantown, results were confirmed on univariate Cox regression, but cause, for example, atherosclerotic coronary West Virginia, USA not multivariate regression (OR 0.773 (0.526 to 1.136); 4 artery disease (CAD). More than 80% of Medicine, John H Stroger p=0.19). Both Kaplan- Meier survival and regression CAAs are atherosclerotic in origin.2 3 Other Hospital of Cook County, analyses showed that dual antiplatelet therapy (DAPT) Chicago, Illinois, USA causative factors include Kawasaki disease, and anticoagulation were not associated with significant 5Department of Medicine, connective tissue disorders, congenital Guthrie Robert Packer Hospital, improvement in MACCE rates. anomalies, infection, specific drug reactions, Sayre, Pennsylvania, USA Conclusion Our analysis showed similar long- term trauma or iatrogenic interventions.4 Potential 6 MACCE risks in patients with CAA undergoing medical, Cardiology, Cleveland Clinic, complications of CAAs include thrombosis, Cleveland, Ohio, USA percutaneous and surgical management. Further, DAPT 7 rupture and embolism, which can precipitate Department of Cardiothoracic and anticoagulation were not associated with significant ischaemia or even sudden death.5 Surgery, Cleveland Clinic, benefits in terms of MACCE rates. These results should Cleveland, Ohio, USA be interpreted with caution considering the small size and The management strategies of CAAs include medical (conservative) therapy, Correspondence to potential for selection bias and should be confirmed in Dr Samir Kapadia; kapadis@ large, randomised trials. percutaneous coronary intervention (PCI) ccf. org and surgery. To date, there is no consensus Khubber S, et al. Open Heart 2021;8:e001440. doi:10.1136/openhrt-2020-001440 1 Open Heart Open Heart: first published as 10.1136/openhrt-2020-001440 on 10 February 2021. Downloaded from on the optimal management of CAAs. This is because the natural history and long‐term outcomes of CAAs remain unclear. In the lack of large randomised clinical trials, current recommendations are primarily based on small studies and anecdotal evidence. Further, controver- sies persist regarding the benefits of anticoagulant and dual antiplatelet therapy (DAPT) in this patient popu- lation.6 7 In this retrospective cohort study, we analysed the long-term major cardiovascular and cerebrovascular event (MACCE) outcomes of patients with CAA who were managed conservatively versus those with PCI or surgical intervention over a 10- year follow- up period. METHODS Patient population This was a single-centre, retrospective cohort study at the Cleveland Clinic. All patients whose cardiac catheterisa- tion reports documented a diagnosis of CAA between Figure 1 Patient selection flow diagram. Flow diagram 2000 and 2005 were included in the present study. CAA depicting the inclusion and exclusion criteria for selection of was defined as a localised dilatation of coronary vascular patients with coronary artery aneurysm. lumen with diameter >1.5 times compared with the refer- ence coronary vessel. Patients reported to have ‘ectasia’ (diffuse dilatation of the coronary vessel) and those with Statistical analysis no recorded follow- up after the initial catheterisation Categorical variables were analysed using the Χ2 test and were excluded from the study. The study was reported expressed as frequency and percentage. Continuous according to the guidelines of the Strengthening and variables were analysed using one-way analysis of vari- Reporting of Observational Studies in Epidemiology ance with post- hoc Tukey’s test, wherever appropriate, 8 Statement checklist. and reported as mean±SD. Univariate analysis was done using the OR; the multivariate analysis was done using Data collection the multivariable binary logistic regression. Kaplan-Meier All patients who underwent coronary arteriography curves were used for survival analysis. A p value cut- off http://openheart.bmj.com/ between 2000 and 2005 were eligible. A total of 74 269 of 0.05 was required for statistical significance. SPSS consecutive cardiac catheterisation reports were searched software (IBM SPSS Statistics for Windows, V.24.0, IBM for the word ‘aneurysm’. This strategy retrieved 3333 Corp) was used for data analysis. catheterisation reports, which were further evaluated to exclude patients with aortic, ventricular and sinus of Vals- RESULTS alva aneurysms. A total of 498 patients matched our inclu- Baseline characteristics sion criteria; however, 40 patients were further excluded The current study included 458 patients, divided into due to incomplete chart information or lack of follow-up three groups: 230 (50.2%) patients were managed medi- on September 27, 2021 by guest. Protected copyright. after the initial catheterisation (figure 1). cally, 176 (38.4%) underwent coronary artery bypass The baseline patient characteristics, aneurysm anatom- grafting (CABG) and 52 (11.3%) underwent PCI. The ical details, and outcomes were collected by a thorough incidence of CAA was 0.7% of the total catheterisa- review of individual medical charts and cardiac catheteri- tion reports. The mean age of the patient population sation images. Mortality data were obtained from multiple was 78±10.5 years, with a male preponderance (N=341; sources in an additive manner, including the Social Secu- 74.5%). Anginal symptoms were reported in 64% of rity Death Index, State Death Index and public record individuals and 32% had a history of congestive heart searches. For patients who did not have any date of death failure. The details of patient baseline characteristics are on record, the date of last known follow-up was used as mentioned in table 1. the censor date. Coronary anatomy and aneurysms Outcome definitions Atherosclerotic CAD was the most common association The primary MACCE endpoint was a composite of all- with CAA, documented in 421 (91.7%) patients. Other cause death, stroke, unplanned percutaneous
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