Scholars Clinical and Experimental Cardiology Journal

Uma Devi K, Naveen T, Sai K M, Sadanand R T, Srinivas G P et.al (2025) Percutaneous Coronary Intervention in Coronary Artery aneurysm Presenting as Anterior Wall Myocardial Infarction Guided by Intravascular Ultrasound (IVUS). Clini & Exp Cardiol J 1(1): 102.

Coronary artery aneurysm (CAA) is a relatively rare condition characterized by abnormal segmental dilatation of the coronary arteries. While many cases of CAA are asymptomatic, symptoms can vary based on the location, size, and extent of the aneurysmal segment. CAA may present with angina, myocardial infarction, or thromboembolic events, complicating its management. Treatment strategies are not well established and are usually directed by the severity of coronary artery obstruction. We present the case of a 53-year-old male with anterior wall myocardial infarction (AWMI) who was incidentally found to have CAA and was successfully managed with percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS) guidance.

Case Presentation

A 53-year-old male with a history of hypertension and diabetes presented with anginal chest pain lasting 4 hours. Electrocardiography revealed findings consistent with AWMI. He was immediately taken for a coronary angiogram which revealed a total occlusion of the proximal left anterior descending artery (LAD). During guidewire passage, a thrombus was identified within an aneurysmal segment of the mid-LAD, causing approximately 90% stenosis from the proximal to mid-LAD. Further evaluation using intravascular ultrasound (IVUS) provided detailed visualization of the thrombotic and aneurysmal segments, as well as the proximal and distal normal landing zones. The patient underwent successful PCI with the placement of a Yukon Choice Flex drug-eluting stent (3.0 x 40 mm), which resulted in the complete exclusion of the aneurysmal segment and maintaining flow in the large diagonal branch with full revascularization. Post-procedure IVUS imaging showed no edge dissection and appropriate minimal stent area.

Conclusion:

This case highlights the importance of IVUS in managing complex cases of CAA associated with myocardial infarction. IVUS provides detailed anatomical insights, allowing precise stent placement and optimal revascularization, even in challenging aneurysmal segments. This case demonstrates that PCI guided by IVUS is an effective therapeutic option for accidentally found CAA, ensuring successful outcomes and improved prognosis.

Coronary artery aneurysm (CAA) is a rare and often overlooked condition characterized by the abnormal segmental dilatation of the coronary arteries. The occurrence of CAA may go undiagnosed due to its asymptomatic nature in many cases [1]. Its clinical significance cannot be overstated, as it has the potential to lead to serious cardiovascular events such as myocardial infarction (MI), angina, and thromboembolic complications [2]. While CAA can occur in isolation, it is frequently associated with other cardiovascular conditions, including atherosclerosis, hypertension, diabetes, or connective tissue disorders [3-5]. The true prevalence of CAA is difficult to ascertain but is generally estimated to range from 0.3% to 4.0% of patients undergoing coronary angiography [6].

The clinical implications of CAA depend largely on the size, location, and associated complications such as thrombosis, rupture, or dissection of the aneurysm. Management strategies for CAA remain variable due to the lack of consensus on optimal treatment approaches. In many cases, treatment decisions are tailored based on the degree of coronary artery obstruction, aneurysm characteristics, and patient co-morbidities [7,8]. Interventional procedures, such as percutaneous coronary intervention (PCI), have emerged as viable treatment options in patients presenting with symptomatic coronary artery aneurysms, particularly in those complicated by acute myocardial infarction (MI).

Intravascular ultrasound (IVUS) is a powerful tool that provides high-resolution, real-time images of the coronary artery lumen and wall structures, facilitating a detailed assessment of the aneurysmal segments, the degree of stenosis, and the surrounding anatomical features. It is especially valuable in complex cases where traditional angiography may fall short in providing adequate information. By improving visualization of coronary artery abnormalities, IVUS aids in accurate decision-making during PCI, ensuring appropriate stent placement and optimal revascularization outcomes.

In this report, we present the case of a 53-year-old male patient who developed an anterior wall myocardial infarction (AWMI) and was incidentally diagnosed with CAA in the left anterior descending artery (LAD). The patient underwent successful PCI with IVUS guidance, which helped ensure precise management of the aneurysm and thrombotic obstruction, ultimately achieving a favorable outcome.

Case Presentation

A 53-year-old male with a five-year history of hypertension, a three-year history of type 2 diabetes mellitus, and a two-year history of hyperlipidemia presented to the emergency department with severe, crushing anginal chest pain lasting approximately four hours. The pain radiated to his left arm and was associated with shortness of breath and diaphoresis. The patient had no prior history of coronary artery disease (CAD) or myocardial infarction (MI) and denied a significant family history of early-onset cardiovascular disease.

On presentation, the patient’s vital signs were stable. Physical examination revealed diaphoresis and an elevated blood pressure of 150/90 mmHg. Electrocardiography (ECG) demonstrated ST-segment elevation in leads V1 to V4, consistent with an anterior wall myocardial infarction, indicative of proximal left anterior descending (LAD) artery involvement. Serum cardiac biomarkers, including Troponin I (66.5 ng/mL), were elevated, confirming acute myocardial infarction. Routine laboratory tests, including hemogram, liver function tests, and renal function tests, were within normal limits. The patient's hemoglobin A1c was 6.5%, indicating controlled diabetes.

Given the clinical presentation of acute coronary syndrome, the patient was promptly referred for coronary angiography. A 6-Fr guiding catheter was advanced into the left main coronary artery, and a wire was passed through the occlusion in the proximal LAD. The coronary angiogram revealed a total acute occlusion in the proximal LAD.

Figure 01:

Coronary angiogram Left injection showing (1A) proximal total occlusion of left anterior descending artery (LAD) pointed by white arrow and (1B) thrombus in the aneurysmal segment of proximal to mid LAD after the guide wire passage pointed by red arrow.

Upon advancing a 0.014-inch workhorse wire, distal LAD flow was restored, revealing 90% stenosis in the proximal to mid-LAD segment, which was complicated by an aneurysmal segment. Further inspection identified a large thrombus located eccentrically within the mid-LAD aneurysmal segment.

Figure 02:

Coronary angiogram Left injection showing (2A) proximal to mid-90% stenosis of left anterior descending artery (LAD) and (2B) thrombus placed eccentrically in the aneurysmal segment of proximal to mid LAD after the guide wire passage.

The aneurysmal segment, located just distal to the occlusion, exhibited a dilated appearance with irregular contours, raising concern for a coronary artery aneurysm.

Given the complex anatomy and the need for optimal visualization during the procedure, intravascular ultrasound (IVUS) was performed to assess lesion morphology and guide the percutaneous coronary intervention (PCI). IVUS revealed a well-defined thrombus-containing aneurysmal segment in the mid-LAD, without evidence of rupture or dissection Notably, IVUS also demonstrated that the proximal and distal LAD segments were free of significant atherosclerotic disease, indicating they were suitable for stent placement.

Figure 03:

Intra Vascular Ultrasound (IVUS) imaging showing (3A) aneurysm in the occlusive segment of left anterior descending artery (LAD) highlighted by white arrow and (3B) thrombus in the aneurysmal segment of mid LAD highlighted by white arrow.

The presence of thrombus within the aneurysmal segment raised concern for potential distal embolization, which could exacerbate myocardial injury. The comprehensive information provided by IVUS guided the decision to proceed with PCI, which aimed to restore coronary flow, eliminate thrombus, and exclude the aneurysmal segment from the circulation.

Due to the complexity of the lesion, the aneurysmal segment was predilated using a high-pressure balloon catheter to prepare the vessel for stent implantation. Subsequently, a 3.0 x 40 mm Yukon Choice Flex drug-eluting stent (DES) was deployed, covering the entire aneurysmal segment. While a covered stent would be the ideal choice for excluding the aneurysm, a DES was used for this case.

Post-stent deployment, IVUS imaging was performed to assess the procedural outcome. IVUS demonstrated no edge dissection or incomplete stent expansion, with an adequate minimal stent area and complete restoration of coronary flow. The thrombotic material was largely cleared, and the aneurysmal segment was fully excluded from the arterial lumen, resulting in successful re-vascularisation with minimal risk of complications.

Figure 04:

Intra Vascular Ultrasound (IVUS) imaging showing (4A) well apposed stent in the left anterior descending artery (LAD) with adequate minimal stent area and (4B) exclusion of the aneurismal segment of mid LAD.

The deployed stent effectively excluded the aneurysmal segment from the coronary circulation while maintaining patency of the LAD and its large diagonal branch on coronary angiography.

Figure 05:

Coronary angiogram Left injection showing (5A) proximal to mid left anterior descending artery (LAD) stent and (5B) well perfused proximal to mid LAD after the guide wire removal.

The patient was closely monitored in the intensive care unit for 24 hours following the procedure. He remained hemodynamically stable, and his chest pain resolved rapidly. Repeat ECG showed resolution of the ST-segment elevation, and serial cardiac biomarkers decreased accordingly. The patient was initiated on appropriate post-PCI pharmacotherapy, including dual antiplatelet therapy, statins, and angiotensin-converting enzyme inhibitors.

The patient was discharged on the third day post-procedure with instructions on lifestyle modification, blood pressure and glucose control, and regular follow-up with his cardiologist. At the 6-months follow-up, the patient reported no further chest pain or symptoms and repeat echocardiography showed normal left ventricular function. Exercise stress test showed good effort tolerance and no evidence of inducible ischemic changes.

Coronary artery aneurysms (CAAs) are a rare but clinically significant condition that may be associated with acute coronary events such as myocardial infarction (MI) [2]. Although the incidence of CAAs is relatively low, their potential to cause serious complications, including coronary artery rupture, distal embolization, and myocardial ischemia, underscores the importance of recognizing and appropriately managing this condition. The etiology of CAA is multifactorial, with atherosclerosis being the predominant cause. However, other factors, including connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome), vasculitis (such as Takayasu arteritis or Kawasaki disease), infections (e.g., syphilis or bacterial endocarditis), and traumatic injury to the coronary artery, have also been identified as contributing factors [3-5]. In some cases, the exact cause of the aneurysm may remain unidentified, as in this patient, where traditional atherosclerotic risk factors such as hypertension and type 2 diabetes mellitus are likely contributors to the development of the coronary aneurysm.

Atherosclerosis, the most common cause of CAAs, leads to the progressive weakening of the arterial wall due to the accumulation of lipids, inflammatory cells, and fibrous tissue. In this process, the vessel wall becomes less elastic and more prone to dilation, eventually forming an aneurysmal segment. In patients with additional risk factors, such as hypertension and diabetes, these processes are often exacerbated, leading to more severe arterial wall damage. The presence of an aneurysm within a coronary artery complicates the clinical scenario, particularly when it is associated with acute myocardial infarction, as it can promote thrombus formation and distal embolization, resulting in further myocardial damage.

The management of CAAs complicated by acute myocardial infarction is complex and requires a comprehensive, multidisciplinary approach. Medical therapy, including antiplatelet agents and anticoagulation, is the first-line treatment for patients with stable symptoms and small, asymptomatic aneurysms. However, when there is significant coronary obstruction, aneurysm-related symptoms (e.g., angina), or evidence of ongoing ischemia, more invasive strategies, such as percutaneous coronary intervention (PCI), may be required. PCI has emerged as a viable and effective treatment modality for patients with symptomatic CAA, particularly when advanced imaging techniques, such as intravascular ultrasound (IVUS), are utilized to guide the intervention.

Intravascular ultrasound (IVUS) plays a critical role in the evaluation and management of CAA by providing high-resolution, real-time, cross-sectional imaging of the coronary artery. IVUS allows for precise assessment of the aneurysm's size, shape, and thrombus burden, which are crucial factors in determining the appropriate therapeutic approach. Moreover, IVUS offers detailed insights into the morphology of the coronary artery, enabling clinicians to evaluate the extent of arterial damage, detect potential complications such as dissection or stent under expansion, and ensure proper stent deployment. In this case, the use of IVUS was instrumental in identifying the thrombus within the aneurysmal segment and confirming the absence of significant disease in the adjacent coronary segments, allowing for tailored intervention.

IVUS-guided PCI offers significant advantages over OCT in the management of coronary artery aneurysms (CAAs), particularly when dealing with large aneurysms. While OCT provides high-resolution imaging of the vessel’s lumen and is particularly useful for assessing smaller lesions, it has limitations when it comes to visualizing large aneurysms or evaluating the full thickness of the vessel wall [9]. IVUS, on the other hand, provides a more comprehensive view, allowing for detailed assessment of both the lumen and the vessel wall, making it ideal for guiding stent placement in cases involving large aneurysms.

In the management of CAA, despite the presence of a large aneurysmal segment, IVUS-guided PCI allows for precise stent selection and placement. In this case, a drug-eluting stent (DES) was chosen over a covered stent, despite the latter being ideal for fully sealing the aneurysm, because IVUS confirmed that the DES would be sufficient to prevent restenosis and maintain long-term patency. The precise imaging from IVUS ensured the stent was deployed correctly, covering the aneurysmal segment and minimizing the risk of thromboembolic events.

Moreover, IVUS offers real-time feedback on procedural complications, such as incomplete stent expansion, edge dissection, or residual stenosis, enabling immediate adjustments to optimize outcomes. Post-procedural IVUS confirmed the successful deployment of the stent, complete restoration of coronary flow, and exclusion of the aneurysmal segment, ensuring a favorable outcome for the patient.

This case highlights the critical role of advanced imaging techniques, such as IVUS, in the management of complex coronary lesions like CAAs. Traditional coronary angiography, while essential for diagnosing coronary artery disease, often lacks the resolution needed to accurately evaluate aneurysms, particularly those that are thrombus-laden or have irregular contours. IVUS provides a more detailed and comprehensive view of the coronary anatomy, which is especially valuable in complex interventions, ensuring that the aneurysmal segment is adequately treated while preserving normal coronary circulation. By offering precise, high-resolution imaging, IVUS enhances decision-making, facilitates safer interventions, and ultimately improves patient outcomes.

This case demonstrates that percutaneous coronary intervention guided by intravascular ultrasound is an effective and safe treatment option for patients with coronary artery aneurysms presenting with acute myocardial infarction. IVUS allows for a detailed understanding of aneurysmal lesions, facilitating precise stent placement and optimal revascularization. In patients with complex coronary anatomy, including those with aneurysms, the use of IVUS significantly enhances procedural success and contributes to improved clinical outcomes. Given its ability to provide detailed anatomical insights, IVUS should be considered an invaluable tool in the management of coronary artery aneurysms, particularly when they are complicated by acute myocardial infarction.

The patient in this case experienced a successful PCI procedure with complete exclusion of the aneurysmal segment, restoration of coronary flow, and resolution of myocardial infarction, highlighting the importance of a tailored, image-guided approach in achieving optimal outcomes in these complex cases.

None

Funding:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Competing interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author contribution:

UDK: Conceptualization; Methodology; Supervision; Writing—original draft; Writing—review and editing. NT: Conceptualization; Methodology, Validation; Writing—original draft; SKM: Writing—review and editing, SRT: Validation; Writing—review and editing, AP: Validation; Writing—review and editing KKK: Validation; Writing- review and editing. All authors reviewed the paper and approved the final version of the manuscript.

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