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Articles Review Article Coronary Artery Aneurysm i ii iii 37 of the wall integrity, as well as transition from the threelay- Third, on the basis of their size, some coronary artery ered wall to an outwardly single/double layer as a result of aneurysms have been referred to as giant coronary artery Review Article disruption of the external elastic membrane16. Pseudoaneu- aneurysms, but a precise size criterion remains unclear18-21. rysms are frequently a result of blunt chest trauma or cathe- In most of the reports, a giant aneurysm has been defined as Coronary Artery Aneurysm: A Review Article ter-based coronary interventions16. when the maximal diameter exceeds 20 mm in adults or 8 mm in children19,20. Malik F, Kalimuddin M, Ahmed N, Badiuzzaman M Pathophysiology Department of Cardiology, National Heart Foundation Hospital & Research Institute, Mirpur, Dhaka The etiology of coronary artery dilatation varies with the geographic location and the age group studied. Table 2 lists Abstract the diverse etiologies for coronary aneurysms. Coronary artery aneurysm (CAA) is defined as any coronary dilatation ≥1.5 times the diameter of the normal adjacent 11 segment or the diameter of the largest coronary vessel. It is an uncommon occurrence, yet it is described more often today Table 2: Etiologies of Coronary Artery Aneurysms than in the past as coronary angiography is now routinely used in the era of interventional cardiology. The incidence varies from 0.3% to 5.3% with male dominance and a predilection for the right coronary artery. Most cases are asymptomatic and atherosclerotic in origin in adults. Advances in imaging (IVUS, high resolution CT and MRI) have provided new insights as to the nature of angiographic coronary aneurysms. Critical assessment of the abnormal flow dynamics and pathophysiology of aneurysms has been performed and there is an improved understanding of the associated complications. Treatment may consist of surgical, percutaneous interventions or medical therapy. We present an extensive review of the recent literature highlighting the major advances in the field. (JNHFB 2016; 5 : 38-43) Introduction With the advent of coronary angiography, coronary artery reported the first case of antemortem diagnosis of a aneurysm has been diagnosed in increasing frequency. coronary artery aneurysm diagnosed by coronary angiogra- Coronary artery aneurysm (CAA) is defined as any coronary phy. The incidence of coronary artery aneurysms ranges dilatation ≥1.5 times the diameter of the normal adjacent widely from 0.3% to 5.3% of the population, based on segment or the diameter of the largest coronary vessel1. The several angiographic studies, and a pooled analysis reports a term ectasia is reserved to mean a diffuse dilatation of a mean incidence of 1.65%8. A study from India reported an coronary artery, and an aneurysm is a focal dilatation of the incidence of 10–12%, the highest in the literature to date, vessel2. CAA can also be visualized on high resolution CT, perhaps reflecting a specific genetic and/or environmental IVUS and MRI. Although some CAA are congenital or predisposition9. The right coronary artery is the most inflammatory, most are atherosclerotic3. There is no consen- commonly affected (40–87% of aneurysms), followed by In Western countries, atherosclerotic aneurysms are most sus on its management, as some advocate conservative the left circumflex or left anterior descending artery, common (50%), followed by congenital (17%) and infec- management while others advocate more aggressive depending on the study10. Three-vessel or left main involve- tious causes (10%); and in Japan, Kawasaki disease approach4. A large aneurysm in the coronary artery makes ment is rare11. Although CAA are seen at any age, those represents the predominant cause of coronary artery 1,22,23 the blood flow turbulent and predisposes to thrombus related to atherosclerosis usually appear later in life than aneurysm . Coronary aneurysms are frequently seen in formation and coronary artery obstruction even without the those of a congenital or inflammatory nature12. Atheroscle- association with atherosclerosis, suggesting an overlap in presence of significant stenosis5. Despite this important rotic or inflammatory CAA are usually multiple and involve risk factors and pathogenesis. It has been estimated that 50% 11 anatomical abnormality of the coronary artery, the treatment more than one coronary artery as compared with congenital, of coronary aneurysms are due to atherosclerosis . The next options are poorly understood and present a therapeutic traumatic, or dissecting aneurysms which are mainly most common cause is congenital, accounting for 20–30% challenge to the interventional cardiologist. While treating single13. The incidence is higher in men than in women of coronary aneurysms. A host of inflammatory and connec- CAAs with percutaneous implantation of covered stents (2.2% vs 0.5%)1,14. tive tissue disorders have also been associated with coronary offers a less invasive option compared to surgical correc- Figure 1: Coronary artery aneurysm compared with coronary artery ectasia. aneurysms. Most well known is the association with Kawa- 5 (a, b) Drawing (a) and coronal reformatted image (b) of a coronary artery saki disease, but coronary aneurysms have also been report- tion, the short- and long-term outcomes are unknown . Classification aneurysm. Drawing (c) and volume-rendered image (d) of coronary artery Herein a review of the literature regarding incidence, classi- Coronary artery aneurysms have been classified in three ectasia n = normal15. ed in patients with Takayasu’s arteritis, lupus, rheumatoid fication, pathophysiology, clinical manifestations, manage- different ways on the basis of the composition of the vessel arthritis, Marfan syndrome, and Ehlers-Danlos syndrome. ment and prognosis of this disease is presented. wall and the morphologic structure (Table 1)15. Comparison Second, coronary artery aneurysms can be classified as Coronary aneurysms have also been noted in conjunction of coronary artery aneurysm with coronary artery ectasia is saccular or fusiform on the basis of their morphologic with infection, drug use, trauma, and percutaneous coronary 11 Incidence shown in figure 1. appearance. In saccular aneurysms, the transverse diameter intervention . Morgagni in 1761, first reported coronary artery aneurysm is greater than the longitudinal measurement of the The pathogenesis for coronary artery aneurysms is usually in a patient with coronary artery dilatation and syphilitic First, coronary artery aneurysms can be either “true” aneurysm, whereas in fusiform aneurysms, the longitudinal related to the underlying cause, but an essential prerequisite aortitis6, but it was not until 1958 when Munkner et al7 aneurysms or “false” aneurysms (pseudoaneurysms), a measurement is greater than the transverse diameter. to aneurysm formation is the presence of an abnormal tunica distinction that is based on the number of layers in the vessel Saccular aneurysms are frequently seen distal to an area of media in the vessel wall (erosion, ulceration, or hemorrhage Corresponding Author wall16. The vessel wall in true aneurysms is composed of proximal related stenosis, are often multisegmental, and are 17 in the tunica media), with resultant enlargement and Professor Fazila-Tun-Nesa Malik three layers: the tunica intima, tunica media, and tunica more prone to thrombosis and rupture . In contrast, Professor & Head, Chief of Cathlab remodeling of an arterial segment, as clearly demonstrated Department of Cardiology adventitia. Conversely, in pseudoaneurysms, there is a loss fusiform aneurysms are not known to be related to a proxi- 17 l8,14, 24–26 National Heart Foundation Hospital & Research Institute, Mirpur, Dhaka mal stenosis . in the atherosclerotic mode . More recently, CAA 38 39 have been described as a consequence of coronary angio- Percutaneous treatment is a newer option that involves the plasty. This was first reported by Holmes et al.27 following placement of a covered stent to obstruct blood flow into the balloon angioplasty (PTCA). The incidence of coronary aneurysmal sac38. The synthetic membrane of the stent-graft artery aneurysms following PTCA ranges widely from 0.3% effectively prevents plaque protrusion, successfully sealing to 3.9%28-29. Proposed mechanisms are: Trauma from the aneurysm— a safer and less invasive alternative in the oversized balloon or high inflation pressures, coronary treatment of coronary aneurysms38 (Figure 2). These dissection, interventions in the setting of acute myocardial PTFE-covered stents, easy and rapid to deploy, have infarction, inflammatory and hypersensitivity reactions to emerged as a new tool for the treatment of coronary artery stent polymers15,30. Early and late development of coronary aneurysms4,39. Polytetrafluoroethylene has ideal characteris- aneurysms following directional atherectomy (DCA) has tics as a single layer, and it can be rolled to form a thin also been well described31,32. Early coronary aneurysms after multilayer covering that can be expanded 4 to 5 times its DCA is related to coronary perforation leading to “pseudo- original diameter (when the stent expands) without lacera- aneurysm” formation, whereas late coronary aneurysms tion or shrinkage. Furthermore, the negative charge of the after DCA are attributed to subintimal damage31. Although polymer prevents blood-protein coagulation on the tissue the molecular mechanism underlying coronary aneurysms surface and limits platelet activation and thrombus forma- has yet
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