A giant coronary artery aneurysm and recurrent ST-segment elevation myocardial infarction: A management dilemna.
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ABSTRACT:
SUBMITTER: Seguy B
PROVIDER: S-EPMC6712981 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThe optimal treatment of aneurysmal or ectatic culprit vessels in the setting of acute myocardial infarction is still matter of debate, as revascularization with either percutaneous intervention or surgery is associated with low procedural success and poor outcomes.Case summaryWe report the case of a 55-year-old male patient, admitted for inferior ST-elevation myocardial infarction, who underwent successful percutaneous implantation of a micro-mesh self-expanding nitinol carotid stent in a right coronary aneurysm with intravascular ultrasonography measured diameter of 9 mm and massive thrombus apposition.DiscussionThe technical characteristics of the micro-mesh self-expanding nitinol carotid stent allow for adequate plaque coverage and good apposition even in large vessels, making this device particularly suitable for the treatment of coronary lesions with high thrombus burden, when severe coronary ectasia or aneurysms are present.
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Project description:Primary PCI of infarct-related arteries is the preferred reperfusion strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI). Up to 40 % of such patients demonstrate evidence of multivessel, non-infarct-related artery coronary disease. Previous non-randomised observational studies and their associated meta-analyses have suggested that in such cases only the culprit infarct-related artery (IRA) lesion should be treated. However, recent randomised controlled trials have demonstrated improved clinical outcomes with lower major adverse cardiovascular events (MACE) rates when complete revascularisation is undertaken either at index primary percutaneous coronary intervention (PPCI) or during index admission. These trials suggest that current guidelines pertaining to treatment of non-infarct-related artery (N-IRA) lesions in STEMI patients with multivessel disease may need to be reconsidered depending on future trials. However, issues remain around timing of N-IRA intervention, the use of fractional flow reserve (FFR) or intravascular imaging to guide intervention in N-IRA lesions and the need to demonstrate reductions in hard clinical endpoints (death and MI) after complete revascularisation; these issues will need to be addressed through future trials. Clinicians must judge on the currently available data, whether it is still safer to leave important stenosis in N-IRA untreated.
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Project description:Electrocardiography and high-sensitivity cardiac troponin testing are routinely applied as the initial step for clinical evaluation of patients with suspected non-ST-segment elevation myocardial infarction. Once diagnosed, patients with non-ST-segment elevation myocardial infarction are commenced on antithrombotic and secondary preventative therapies before undergoing invasive coronary angiography to determine the strategy of coronary revascularisation. However, this clinical pathway is imperfect and can lead to challenges in the diagnosis, management, and clinical outcomes of these patients. Computed tomography coronary angiography (CTCA) has increasingly been utilised in the setting of patients with suspected non-ST-segment elevation myocardial infarction, where it has an important role in avoiding unnecessary invasive coronary angiography and reducing downstream non-invasive functional testing for myocardial ischaemia. CTCA is an excellent gatekeeper for the cardiac catheterisation laboratory. In addition, CTCA provides complementary information for patients with myocardial infarction in the absence of obstructive coronary artery disease and highlights alternative or incidental diagnoses for those with cardiac troponin elevation. However, the routine application of CTCA has yet to demonstrate an impact on subsequent major adverse cardiovascular events. There are several ongoing studies evaluating CTCA and its associated technologies that will define and potentially expand its application in patients with suspected or diagnosed non-ST-segment elevation myocardial infarction. We here review the current evidence relating to the clinical application of CTCA in patients with non-ST-segment elevation myocardial infarction and highlight the areas where CTCA is likely to have an increasing important role and impact for our patients.
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Project description:Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.
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Project description:Coronary artery aneurysm (CAA) presenting as an ST-elevation myocardial infarction (STEMI) represents a clinical challenge due to the technical difficulties in the percutaneous management of this specific situation. Appropriate treatment for CAA depends on the precise clinical situation and consists of medical management, surgical resection, or/and stent placement. The high rate of complications during percutaneous intervention (distal thrombus embolization, no-reflow phenomenon, stent malposition, or dissection) makes emergent surgery a frequent situation in these cases. We present the case of a 50-year-old man with a STEMI due to thrombotic occlusion of CAA. Specific angiographic techniques and intracoronary imaging help with the percutaneous management of acute thrombotic occlusions in CAA, providing a less invasive approach than emergent surgery.
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