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Coronary Aneurysms: What Every Radiologist Should Know

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  • 1. Garry Choy, MD1; Brian Ghoshhajra, MD, MBA1; Terrance T. Healey, MD2; Carlos A. Rojas, MD1; Efren Flores, MD1; Axel Scherer, MD3; Sung Han Kim, MD4; Suhny Abbara, MD1 Coronary Aneurysms: What Every Radiologist Needs to Know 1Department of Radiology, MASSACHUSETTS GENERAL HOSPITAL • 1,4HARVARD MEDICAL SCHOOL • 4Mt. Auburn Hospital • 2Department of Radiology, Rhode Island Hospital, Brown Medical School • 3 Institute of Diagnostic Radiology, Heinrich-Heine University References 1. Abbara, S, Walker TG. Diagnostic Imaging: Cardiovascular. Amirsys. 2008. 2. Baker AL, Newburger JW. Kawasaki disease. Circulation 2008;118: e110-2. 3. European Coronary Surgery Study Group. Prospective randomized study of coronary artery bypass surgery in stable angina pectoris. Lancet. 1980; 2:491–495. 4. Ghanta RK, Paul S, Couper GD. Successful revascularization of multiple coronary artery aneurysms using a combination of surgical strategies. Ann Thorac Surg. 2007; 84: e10–e11. 5. Harandi S, Johnston SB, Wood RE, et al. Operative therapy of coronary arterial aneurysm. Am J Cardiol. 1999; 83:1290–1293. 6. Hartnell GG, Parnell BM, Pridie RB. Coronary artery ectasia: its prevalence and clinical significance in 4993 patients. Br Heart J. 1985; 54:392–395. 7. Murthy PA, MohammedTL, Read K, Gilkeson RC,White CS. MDCT of coronary artery aneurysms. AJR Am J Roentgenol 2005;184:S19-20. 8. Takaki MT, Dubinsky TJ, Warren BH, Mitsumori L, Shuman WP. Nonatherosclerotic cardiovascular findings on MDCT coronary angiography: a selection of abnormalities. AJR Am J Roentgenol 2008;190:934-46. 9. Satran A, Bart BA, Henry CR, Murad MB, Talukdar S, Satran D, Henry TD. Increased prevalence of coronary artery aneurysms among cocaine users. Circulation. 2005 May 17;111(19):2424-9. Epub 2005 May 9. 10. ECG-gated Cardiac CT Evaluation of a Saphenous Vein Graft Aneurysm Pre- and Post- Percutaneous Intervention, Rojas CA, MD, El-Sherief A., MD, Choy G., MD, Medina-Zulaga H., MD, Inglessis I., MD, Abbara S., MD and Mamuya W., MD, Cardiovascular Images, Massachusetts General Hospital, 2009 http://www.mgh-cardiovascimages.org/ PURPOSE To review the variety and range of coronary artery and bypass graft aneurysms To discuss the findings and diagnostic criteria To explain the pathological processes What is a coronary artery aneurysm? Definition Coronaryarterydiameter>1.5Xnormaladjacentsegdiameter Types • Focal or diffuse • Fusiform or saccular Clinical Implications • Often asymptomatic but patients can present with angina, myocardial infarction, or sudden death • Otheradverseeventsincludethrombosis,thromboembolism, AV fistulae, vasospasm, and rupture • Incidental finding on coronary angiograms Pathophysiology Thought to be similar to that for aneurysms of larger vessels, with destruction of the vessel media resulting in increased wall stress and subsequent dilation Epidemiology • Atherosclerosis most common cause in USA • Kawasaki Disease most common cause globally • Based on several angiographic studies, incidence of coronary artery aneurysms ranges from 0.3% to 5.3% of the population • Incidence has been reported in up to 1.8% in an angiographic study [ref: Nichols] • Right coronary artery is most commonly affected (40–87% of aneurysms), followed by left circumflex or left anterior descending artery, depending on the study [ref: Villines] • Three-vessel or left main involvement is rare Best imaging tool • Coronary CTA or Coronary angiography • Goal is to establish diagnosis and to provide additional information about size, shape, location, and number of existing anomalies • Imagingiscriticalinfollow-uptoensurestabilityofaneurysms Treatments • Anticoagulants, antiplatelet therapy, bypass, covered stents • Treatment options consist of surgical, percutaneous, and medical approaches • At mean of 3.2 years follow-up, mortality rates after surgery and medical management were 7.7% and 13% where follow-up was available), respectively •Similarmortalityratesat5yrswerereportedinEuropean CoronarySurgeryStudyofpatientstreatedsurgically ormedically • Operative therapy includes CABG, aneurysm ligation, resection, or marsupialization with interposition graft • Percutaneous treatment is a newer option and includes stenting and coiling Morphology of Coronary Artery Aneurysms Fusiform or saccular dilatation Can be associated with thrombosis Atherosclerotic Disease Findings Fig 1A - B: Atherosclerotic aneurysmal dilatation of the distal left main to 9 mm, with continuation of aneurysm into the proximal LAD Fig 2A - B: Massive atherosclerotic left main to LAD coronary aneurysm in a different patient Fig 3A, B, C: Saccular aneurysm in setting of Atherosclerotic Disease in proximal LAD Teaching Points - Atherosclerotic Disease Most common cause in USA Male-predominant Pathophysiology Atherosclerotic related inflammation-mediated thinning or destruction of media; increased MMP (matrix metalloproteinase) activity resulting in proteolysis of extracellular matrix proteins have been implicated in atherosclerosis Symptoms and complications related to concurrent degree of CAD or obstructive coronary disease Teaching Points – Cocaine Cocaine mediated aneurysms have a similar appearance as aneurysms related to atherosclerotic disease Coronary aneurysms and occur between 0.2% to 5.3% of patients referred for angiography T. Henry, et al found that among cocaine users, up to 30% in a study of 112 patients had coronary artery aneurysms Average age was 44 years old and predominantly male Potential pathophysiological mechanism may be tied to chemically-mediated severe local episodic hypertension and vasoconstriction with direct endothelial damage predisposing to aneurysm formation Saccular or fusiform morphology of aneurysms not unlike in appearance with aneurysms found in atherosclerotic disease Etiologies of Coronary Aneurysms Atherosclerotic Disease (Most common cause in USA) Kawasaki Disease (Most common cause worldwide) Connective Tissue Disease (SLE, Marfan, Behcet’s Disease) Pseudoaneurysms Saphenous Vein Graft Aneurysm Post-Traumatic Pseudoaneurysm Infection Coronary Fistulas Cocaine Use Connective Tissue Disease - Marfan Syndrome Findings Fig 16A, B, C, D: Patient with both sinus of Valsalva aneurysm and fusiform aneurysm involving distal left main, proximal LAD, proximal LCX in setting of Marfan Syndrome. Only minimal atherosclerotic disease with tiny focus calcification seen in distal left main Teaching Points – Connective Tissue Disease Pathophysiology Linked to excess TGF-beta production (protein that is homologous with family of proteins in microfibrils in elastin fibers) Examples of connective tissue diseases associated with coronary aneurysms: Marfan Syndrome: Mutation in gene encoding fibrillin; cystic medial degeneration common feature of aneurysms Behcet’s: Form of vasculitis associated with systemic vascular inflammation; patients also present with oral ulcers, genital ulcers, skill lesions, uveitis Kawasaki Disease Findings Fig 4A, B, C, D: Fusiform dilatation of the proximal RCA in patient with minimal atherosclerosis and history of Kawasaki Disease Fig 5A, B, C: Multiple fusiform aneurysms in proximal RCA and LAD. Calcification possibly related to chronic nature of thrombosis in setting of Kawasaki Disease Fig 6: Partially thrombosed RCA aneurysm in patient with Kawasaki Disease Fig 7A - B: Multiple partially calcified fusiform aneurysms in LAD and diagonal branch in patient with Kawasaki Disease. Teaching Points – Kawasaki Disease Kawasaki Disease - mucocutaneous lymph node syndrome; self limited systemic vasculitis of childhood affecting multiple systems including coronary arteries Epidemiology Mainly Asian population, 50/100,000 children in Japan (10X higher incidence than US) Pathophysiology Generalized systemic vasculitis involving large, medium sized arteries associated with aneurysm and thrombosis Cardiac findings in Kawasaki Disease include myocarditis, coronary aneurysms, or arrhythmias Kawasaki Disease patients at risk for thrombosis due to increased platelets (thrombosis often found in aneurysms); aneurysms may not be discovered until adulthood Treatment Antiplatelet or anticoagulation therapy Post-Traumatic Pseudoaneurysm Findings Fig 8: This patient underwent balloon angioplasty and stenting of the left main to LAD and circumflex after acute occlusion. Follow-up catheterization 2 weeks later for recurrent chest pain demonstrates a post- traumatic pseudoaneurysm at the angioplasty and stent site. Follow-up CTA 3 months later demonstrates near-complete resolution Fig 9: Pseudoaneurysm of the left main in a different patient after balloon angioplasty Fig 10: Catheter angiogram demonstrates an aneurysmal saphenous vein graft Fig 11: Unenhanced axial CT demonstrates mural thrombus in the aneurysm Fig 12A, B, C, D: Enhanced CTA demonstrates the lumen and the true diameter of the aneurysm Note the dilated apical aneurysm and calcified papillary muscle, confirming a remote MI Figure 13A: Pre-intervention axial multiplanar reformation (MPR) image demonstrating a large SVG aneurysm with associated thrombus within the aneurysm Figure 13B: Pre-intervention coronal maximum intensity projection (MIP) image demonstrating a large SVG-PLV aneurysm Figure 13C: Post-intervention axial MPR image demonstrating successful stenting and exclusion of the SVG-PLV aneurysm Figure 13D: Post-intervention coronal MIP image demonstrating successful exclusion of the SVG-PLV aneurysm, without evidence of an endoleak Fig 14A, B, C: Extremely large Saphenous Vein Graft Pseudoaneurysm with associated median sternotomy dehiscence Fig 15A, B, C: Mycotic Pseudoaneurysm – Infection/Traumatic Images demonstrate a patient with inflammatory pericarditis from group B streptococcus infection. 6 weeks prior, pericardiocentesis revealed Group-C-Streptococci. No history of childhood illness nor connective tissue disease. CTA shows focal saccular aneurysm of the RCA. Rim-enhancing pericardial fluid collection along the left lateral border of the heart Fig 15D: Double-Oblique Coronal. Arterial-phase gated CTA demonstrates a 2-3 cm collection of contrast in continuity with the distal RCA. Narrow connection to parent vessel Fig 15E: Catheter Coronary Angiography. Coronary angiography demonstrates collection of contrast in distal RCA confirming CTA finding Fig 15F: Post-Stent CTA (with residual contrast in excluded sac). Because of the tenuous condition of the patient, a covered stent was placed in the RCA. In order to secure a landing zone, the PDA was sacrificed. The patient suffered a small inferior wall MI Teaching Points - Pseudoaneurysm Most commonly, pseudoaneurysms are post-traumatic in nature related to intervention or surgery such as CABG, cardiac angiography in setting of stent placement or angioplasty or pericardiocentesis Infection may also result in pseudoaneurysm Fig 01A Fig 01B Fig 02A Fig 02B Fig 03A Fig 03B Fig 03C Fig 04A Fig 04B Fig 04C Fig 04D Fig 05A Coronary Fistulas Findings Fig 17A - B: Anterior and inferior-posterior volume rendered images demonstrate an enlarged, tortuous RCA, with the PLV branch connecting to the coronary sinus (arrow). Flow therefore shunts from the high-pressure coronary artery to the low-pressure coronary sinus Fig 18A - B: Coronary fistula of left circumflex artery (LCX) to the coronary sinus. The LCX (red arrow) is diffusely ectatic with a large focal aneurysm (yellow arrow) immediately proximal to anastamosis with coronary sinus (orange arrow) Teaching Points – Coronary Fistulas Consider coronary fistula as a differential consideration when aneurysmal dilatation of coronary artery is seen Abnormal direct connection between coronary artery and a cardiac chamber Etiology Usually congenital in nature Latrogenic after biopsy or intervention Trauma Connects high pressure system to low pressure system Best imaging findings Tortuous and enhancing epicardial arteries Markedly enlarged and tortuous coronary arteries; aneurysmal dilatation immediately proximal to drainage site Fig 05B Fig 05C Fig 06 Fig 07A Fig 07B Fig 08 Fig 09 Fig 10 Fig 11 Fig 12A Fig 12B Fig 12C Fig 12D Fig 14A Fig 14B Fig 14C Fig 15A Fig 15B Fig 15C Fig 15D Fig 15E Fig 15F Fig 16A Fig 16B Fig 16C Fig 16D Fig 17A Fig 17B Fig 18A Fig 18B Fig 13A Fig 13B Fig 13C Fig 13D

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