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Coronary aneurysm: At a glance and Management.pptx

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abhishek tiwari

This document discusses coronary artery aneurysms (CAAs). It defines a CAA as a dilatation of the coronary artery exceeding 50% of the reference vessel diameter. CAAs can be classified based on their morphology, vessel wall composition, and the vessels affected. Common risk factors include atherosclerosis, vasculitis, and intracoronary manipulation. CAAs are often asymptomatic but can occasionally cause symptoms. Diagnosis is typically via coronary angiography. Management involves medical therapy, percutaneous interventions such as stenting, or surgery, with challenges that include proper sizing and coverage of aneurysmal segments.

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CORONARY ANEURYSM ABHISHEK KUMAR TIWARI DM RESIDENT COIMBATORE MEDCAL COLLEGE AND HOSPITAL
Dilatation of the coronary artery exceeding 50% of the reference vessel diameter.[1] DEFINITION
Dilatation of the coronary artery exceeding 50% of the reference vessel diameter.[1] Giant if DIAMETER >8 MM 4 times of referance vessel. DEFINITION
5% of patients undergoing CAG A/W poor long term outcomes. M> F Proximal > Distal RCA > LAD >> LMCA EPIDEMIOLOGY
Atherosclerotic and vasculitic CAAs > 1 artery. Congenital and iatrogenic CAAs confined to a single vessel. EPIDEMIOLOGY
. ANEURYSM VERSUS ECTASIA CORONARY ANEURYSM CORONARY ECTASIA Focal dilation of at least1.5 times the adjacent normal segment Diffuse dilation of at least1.5 times the adjacent normal segment
TYPES- MORPHOLOGY
TYPES- VESSEL WALL COMPOSITION True aneurysm: preserved vessel wall integrity with 3 layers(intima, media, and adventitia) Pseudoaneurysm: loss of vessel wall integrity and damage to the adventitia
TYPES- ECTASIA Type I: diffuse ectasia of 2 or 3 vessels Type II: diffuse disease in 1 vessel and localized disease in another vessel Type III: diffuse ectasia in 1 vessel Type IV: localized or segmental ectasia
Coronary aneurysm: At a glance and Management.pptx
RISK FACTORS 1. Genetic susceptibility. 2. Atherosclerosis (Proteolysis of ECM) 3. Vasculitis (Kawasaki, Takayasu) 4. Connective tissue diseases
RISK FACTORS 5. Intracoronary manipulation ( CAG, PCI, BRACHYTHERAPY) 6. DES due to the impaired intimal healing effects of the antiproliferative agents. 6.Post-infectious CAAs. ( Direct or Immune)
CLINICAL PRESENTATION 1. Mostly asymptomatic detected incidentally on CAG/CT
CLINICAL PRESENTATION Clinical symptoms can develop due to - 1) Concomitant atherosclerosis 2) Local thrombosis 3) Massive enlargement of some CAAs can result in compression of adjacent structures 4) Aneurysm rupture Tamponade 5) Stress-induced myocardial ischemia due to microvascular dysfunction
Coronary aneurysm: At a glance and Management.pptx
Delayed antegrade contrast filling, segmental back flow, and contrast stasis in the dilated coronary segment often hamper optimal imaging in CAG A forceful and prolonged injection avoid misinterpreting slow aneurysmal filling as in situ thrombosis, especially in giant aneurysms
(IVUS) Better delineation of vessel wall. Distinguish between true & pseudoaneurysm, and segments with aneurysmal appearance due to plaque rupture or adjacent stenosis. IVUS can also accurately size the CAA and/or any adjacent stenoses and allows proper stent sizing if PCI is planned.
Caution should be exercised when IVUS assessment is performed post-stenting to avoid dislodgment of the stent. OCT Small scan diameter of Infrared radiation-
CT is particularly helpful in patients with giant CAA, Avoids the pitfalls of luminal angiography and provides a precise assessment of mechanical complications of these aneurysms
PITFALLS OF MANAGEMENT STRATEGY The natural history is largely unknown. Hence, the optimal treatment of incidentally found CAA or coronary ectasia- uncertain. With angina or acute MI- PCI/Surgery - Challenging Lack of randomized trials or large-scale data.
MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD.
MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD. Current guidelines recommend anticoagulation only in selected Kawasaki patients with large or rapidly expanding CAA.
MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD. Current guidelines recommend anticoagulation only in selected Kawasaki patients with large or rapidly expanding CAA. Some authors suggest use of ACE-INot proven.
MEDICAL MANGEMENT Nitrates/ vasodilators- Avoided
MEDICAL MANGEMENT Nitrates/ vasodilators- Avoided. IVIG may regress CAA in Kawasaki disease.
PERCUTANEOUS INTERVENTIONS PCI of an aneurysmal/ectatic culprit vessel in the setting of acute MI is associated with lower procedural success and a higher incidence of no- reflow and distal embolization
PERCUTANEOUS INTERVENTIONS PCI of an aneurysmal/ectatic culprit vessel in the setting of acute MI is associated with lower procedural success and a higher incidence of no- reflow and distal embolization. Post PCI higher mortality, higher stent thrombosis, target vessel revascularization, and MI during intermediate-term follow-up
Coronary aneurysm: At a glance and Management.pptx
RECOMMENDED MANAGEMENT Due to the higher associated thrombus burden, PCI in ectatic and aneurysmal arteries is frequently aided with thrombectomy (aspiration or mechanical), and glycoprotein IIb/IIIa inhibitors
stumped ostial LAD
Initial angiogram following proximal LAD stenting
Initial angiogram showing proximal RCA fusiform aneurysm
Follow-up angiogram 4 years later showing patent proximal LAD stent but worsening mid-LAD and circumflex stenoses (arrow) and enlarging proximal RCA fusiform aneurysm
Severe stenosis in the distal RCA. Note the deep-seated Amplatz guiding catheter in the proximal RCA. Guide-induced proximal RCA dissection noted after stenting the distal RCA. Successful treatment of the dissection with drug-eluting stents.
Angiogram 8 years later showing an occluded mid RCA and a possible pseudoaneurysm of the proximal RCA (site of prior stenting). Successful treatment of the RCA STEMI with drug-eluting stents.Successful exclusion of the coronary pseudoaneurysm with a GRAFTMASTER covered stent
Moderate Size Saccular Aneurysm in the Mid-LAD Treated With a Modified Stent-Assisted Coil Embolization
Coronary aneurysm: At a glance and Management.pptx
PTCA CHALLENGES No covered stents that are specifically designed for CAAs. For diameters between 2.75 and 5 mm, the GRAFTMASTER coronary stent graft MC used.
PTCA CHALLENGES No covered stents that are specifically designed for CAAs. For diameters between 2.75 and 5 mm, the GRAFTMASTER coronary stent graft MC used.
PTCA CHALLENGES High failure rate dute to high thrombus burden. AngioJet thrombectomy device small trials demonstrated its efficacy in patients with CAA
PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration.
PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration. Partially thrombosed CAA underestimation of the true size of the aneurysm.
PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration. Partially thrombosed CAA underestimation of the true size of the aneurysm. In long aneurysmal segments, several overlapping stents are often needed to cover the full length of the aneurysm
PTCA CHALLENGES Covered stents are stiff and are delivered via large coronary guiding catheters More Complications.
PTCA CHALLENGES Cases where covered stent not possible, the stent- assisted coil embolization technique, can be used. With this technique, a microcatheter is usually placed in the aneurysm before stenting.
PTCA CHALLENGES Cases where covered stent not possible, the stent- assisted coil embolization technique, can be used. With this technique, a microcatheter is usually placed in the aneurysm before stenting. A regular coronary stent is then deployed in the aneurysmal segment at low pressure, and coils can then be passed through the microcatheter to wrap around the stent. Post-dilation of stent is then performed. Additional coils can be advanced via the stent struts if needed
Coronary aneurysm: At a glance and Management.pptx
KAWASAKI GUIDELINES Current American Heart Association guidelines recommend restricting PCI in Kawasaki patients to those with a single- vessel or focal multivessel disease
SURGERY The ideal surgical approach has not yet been formally studied. Operative therapy for CAA may include aneurysm ligation, resection, or marsupialization with interposition graft. The most common surgical practice is, however, to open the CAA, suture its afferent and efferent vessels, and finish with bypass grafting if necessary
Coronary aneurysm: At a glance and Management.pptx
Coronary aneurysm: At a glance and Management.pptx
MANAGEMENT of POST THROMBOLYSIS BLEED Immediately stop ongoing infusion of thrombolytic drug, and stop all antiplatelet and anticoagulant therapies. Investigate according to site of haemorrhage (e.g. CT brain, CT abdo/pelvis) Obtain blood tests: FBC, coagulation profile; repeat q2h until bleeding controlled obtain cross match
MANAGEMENT of POST THROMBOLYSIS BLEED Reverse fibrinolysis: FFP 2 units q6h for 24h cryoprecipitate 10 units tranexamic acid 1g IV ? role of prothrombinex and Factor 7 Reverse anti-platelet effects: platelets 1 adult bag DDAVP 0.3 microg/kg
MANAGEMENT of POST THROMBOLYSIS BLEED Reverse anti-coagulant effects: protamine 1 mg for every 100 U of unfractionated heparin given in the preceding 4 hours protamine 1 mg for every 1 mg of enoxaparin (or 100 units of dalteparin) given in the preceding 8 hours
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Coronary aneurysm: At a glance and Management.pptx

  • 1. CORONARY ANEURYSM ABHISHEK KUMAR TIWARI DM RESIDENT COIMBATORE MEDCAL COLLEGE AND HOSPITAL
  • 2. Dilatation of the coronary artery exceeding 50% of the reference vessel diameter.[1] DEFINITION
  • 3. Dilatation of the coronary artery exceeding 50% of the reference vessel diameter.[1] Giant if DIAMETER >8 MM 4 times of referance vessel. DEFINITION
  • 4. 5% of patients undergoing CAG A/W poor long term outcomes. M> F Proximal > Distal RCA > LAD >> LMCA EPIDEMIOLOGY
  • 5. Atherosclerotic and vasculitic CAAs > 1 artery. Congenital and iatrogenic CAAs confined to a single vessel. EPIDEMIOLOGY
  • 6. . ANEURYSM VERSUS ECTASIA CORONARY ANEURYSM CORONARY ECTASIA Focal dilation of at least1.5 times the adjacent normal segment Diffuse dilation of at least1.5 times the adjacent normal segment
  • 8. TYPES- VESSEL WALL COMPOSITION True aneurysm: preserved vessel wall integrity with 3 layers(intima, media, and adventitia) Pseudoaneurysm: loss of vessel wall integrity and damage to the adventitia
  • 9. TYPES- ECTASIA Type I: diffuse ectasia of 2 or 3 vessels Type II: diffuse disease in 1 vessel and localized disease in another vessel Type III: diffuse ectasia in 1 vessel Type IV: localized or segmental ectasia
  • 11. RISK FACTORS 1. Genetic susceptibility. 2. Atherosclerosis (Proteolysis of ECM) 3. Vasculitis (Kawasaki, Takayasu) 4. Connective tissue diseases
  • 12. RISK FACTORS 5. Intracoronary manipulation ( CAG, PCI, BRACHYTHERAPY) 6. DES due to the impaired intimal healing effects of the antiproliferative agents. 6.Post-infectious CAAs. ( Direct or Immune)
  • 13. CLINICAL PRESENTATION 1. Mostly asymptomatic detected incidentally on CAG/CT
  • 14. CLINICAL PRESENTATION Clinical symptoms can develop due to - 1) Concomitant atherosclerosis 2) Local thrombosis 3) Massive enlargement of some CAAs can result in compression of adjacent structures 4) Aneurysm rupture Tamponade 5) Stress-induced myocardial ischemia due to microvascular dysfunction
  • 16. Delayed antegrade contrast filling, segmental back flow, and contrast stasis in the dilated coronary segment often hamper optimal imaging in CAG A forceful and prolonged injection avoid misinterpreting slow aneurysmal filling as in situ thrombosis, especially in giant aneurysms
  • 17. (IVUS) Better delineation of vessel wall. Distinguish between true & pseudoaneurysm, and segments with aneurysmal appearance due to plaque rupture or adjacent stenosis. IVUS can also accurately size the CAA and/or any adjacent stenoses and allows proper stent sizing if PCI is planned.
  • 18. Caution should be exercised when IVUS assessment is performed post-stenting to avoid dislodgment of the stent. OCT Small scan diameter of Infrared radiation-
  • 19. CT is particularly helpful in patients with giant CAA, Avoids the pitfalls of luminal angiography and provides a precise assessment of mechanical complications of these aneurysms
  • 20. PITFALLS OF MANAGEMENT STRATEGY The natural history is largely unknown. Hence, the optimal treatment of incidentally found CAA or coronary ectasia- uncertain. With angina or acute MI- PCI/Surgery - Challenging Lack of randomized trials or large-scale data.
  • 21. MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD.
  • 22. MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD. Current guidelines recommend anticoagulation only in selected Kawasaki patients with large or rapidly expanding CAA.
  • 23. MEDICAL MANGEMENT No Clear guidelines supporting dual antiplatelets/ anticoagulation for CAA/CAE without CAD. Current guidelines recommend anticoagulation only in selected Kawasaki patients with large or rapidly expanding CAA. Some authors suggest use of ACE-INot proven.
  • 24. MEDICAL MANGEMENT Nitrates/ vasodilators- Avoided
  • 25. MEDICAL MANGEMENT Nitrates/ vasodilators- Avoided. IVIG may regress CAA in Kawasaki disease.
  • 26. PERCUTANEOUS INTERVENTIONS PCI of an aneurysmal/ectatic culprit vessel in the setting of acute MI is associated with lower procedural success and a higher incidence of no- reflow and distal embolization
  • 27. PERCUTANEOUS INTERVENTIONS PCI of an aneurysmal/ectatic culprit vessel in the setting of acute MI is associated with lower procedural success and a higher incidence of no- reflow and distal embolization. Post PCI higher mortality, higher stent thrombosis, target vessel revascularization, and MI during intermediate-term follow-up
  • 29. RECOMMENDED MANAGEMENT Due to the higher associated thrombus burden, PCI in ectatic and aneurysmal arteries is frequently aided with thrombectomy (aspiration or mechanical), and glycoprotein IIb/IIIa inhibitors
  • 31. Initial angiogram following proximal LAD stenting
  • 32. Initial angiogram showing proximal RCA fusiform aneurysm
  • 33. Follow-up angiogram 4 years later showing patent proximal LAD stent but worsening mid-LAD and circumflex stenoses (arrow) and enlarging proximal RCA fusiform aneurysm
  • 34. Severe stenosis in the distal RCA. Note the deep-seated Amplatz guiding catheter in the proximal RCA. Guide-induced proximal RCA dissection noted after stenting the distal RCA. Successful treatment of the dissection with drug-eluting stents.
  • 35. Angiogram 8 years later showing an occluded mid RCA and a possible pseudoaneurysm of the proximal RCA (site of prior stenting). Successful treatment of the RCA STEMI with drug-eluting stents.Successful exclusion of the coronary pseudoaneurysm with a GRAFTMASTER covered stent
  • 36. Moderate Size Saccular Aneurysm in the Mid-LAD Treated With a Modified Stent-Assisted Coil Embolization
  • 38. PTCA CHALLENGES No covered stents that are specifically designed for CAAs. For diameters between 2.75 and 5 mm, the GRAFTMASTER coronary stent graft MC used.
  • 39. PTCA CHALLENGES No covered stents that are specifically designed for CAAs. For diameters between 2.75 and 5 mm, the GRAFTMASTER coronary stent graft MC used.
  • 40. PTCA CHALLENGES High failure rate dute to high thrombus burden. AngioJet thrombectomy device small trials demonstrated its efficacy in patients with CAA
  • 41. PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration.
  • 42. PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration. Partially thrombosed CAA underestimation of the true size of the aneurysm.
  • 43. PTCA CHALLENGES Proper sizingkey to reducing the risk of stent thrombosis and stent migration. Partially thrombosed CAA underestimation of the true size of the aneurysm. In long aneurysmal segments, several overlapping stents are often needed to cover the full length of the aneurysm
  • 44. PTCA CHALLENGES Covered stents are stiff and are delivered via large coronary guiding catheters More Complications.
  • 45. PTCA CHALLENGES Cases where covered stent not possible, the stent- assisted coil embolization technique, can be used. With this technique, a microcatheter is usually placed in the aneurysm before stenting.
  • 46. PTCA CHALLENGES Cases where covered stent not possible, the stent- assisted coil embolization technique, can be used. With this technique, a microcatheter is usually placed in the aneurysm before stenting. A regular coronary stent is then deployed in the aneurysmal segment at low pressure, and coils can then be passed through the microcatheter to wrap around the stent. Post-dilation of stent is then performed. Additional coils can be advanced via the stent struts if needed
  • 48. KAWASAKI GUIDELINES Current American Heart Association guidelines recommend restricting PCI in Kawasaki patients to those with a single- vessel or focal multivessel disease
  • 49. SURGERY The ideal surgical approach has not yet been formally studied. Operative therapy for CAA may include aneurysm ligation, resection, or marsupialization with interposition graft. The most common surgical practice is, however, to open the CAA, suture its afferent and efferent vessels, and finish with bypass grafting if necessary
  • 52. MANAGEMENT of POST THROMBOLYSIS BLEED Immediately stop ongoing infusion of thrombolytic drug, and stop all antiplatelet and anticoagulant therapies. Investigate according to site of haemorrhage (e.g. CT brain, CT abdo/pelvis) Obtain blood tests: FBC, coagulation profile; repeat q2h until bleeding controlled obtain cross match
  • 53. MANAGEMENT of POST THROMBOLYSIS BLEED Reverse fibrinolysis: FFP 2 units q6h for 24h cryoprecipitate 10 units tranexamic acid 1g IV ? role of prothrombinex and Factor 7 Reverse anti-platelet effects: platelets 1 adult bag DDAVP 0.3 microg/kg
  • 54. MANAGEMENT of POST THROMBOLYSIS BLEED Reverse anti-coagulant effects: protamine 1 mg for every 100 U of unfractionated heparin given in the preceding 4 hours protamine 1 mg for every 1 mg of enoxaparin (or 100 units of dalteparin) given in the preceding 8 hours