609 Multimodality imaging for definition and treatment selection of multiple coronary aneurysms

Aims: A 59 years-old woman, smoker, hypertensive, without previous history of CAD referred several episodes of epigastric pain unrelated to physical activity. After exer- cise ECG and considering the risk profile, coronary angiography was indicated. It revealed extensive coronary calcification, with a nodular calcific structure adjacent to the proximal, sub-occluded, left anterior descending (LAD) and a calcified aneurysm of the right coronary artery (RCA), partially filled with thrombus, causing sub-critical stenosis. Coronary-CT showed aneurysmal saccular dilatation of the prox- imal LAD (15x13x13mm) entirely thrombosed with sub-occlusion; and a fusiform aneurysm in the proximal RCA (25x22x24mm), partially thrombosed, with stenosis at the distal portion. The patient was referred for surgical treatment to receive arterial graft with left internal mammary artery to LAD. Methods and results: In our case, congenital aetiology of the aneurysms was unlikely, since the patient did not present congenital heart disease or known genetically inherited disorders. Among acquired aneurysms, the most common cause is repre- sented by atherosclerosis. Other potential causes are Connective tissue disorders, trauma, infections, Iatrogenic and Kawasaki syndrome. The latter represents, with atherosclerosis, the most likely causes of aneurysmal disease in our patient. Multiple CAAs, mural calcification and luminal thrombosis are typical of both Kawasaki disease and atherosclerosis. Evidence of coronary stenosis and atherosclerotic plaque (even in other vessels) is an additional helpful finding for atheroaneurysmal disease. Usual complications include myocardial ischemia and infarction, embolism, rupture, fistuli- zation and thrombosis (clearly represented in our case). Current recommendations about management strategies of CAAs are focused on small case series and based on aneurysm’s location and morphology, patient’s characteristics, and clinical presenta- tion. Medical treatment strategies include antiplatelet therapy, or anticoagulant (in selected Kawasaki patients with large or rapidly expanding CAA). Other therapeutical options are PCI and CABG. The decision to intervene on CAA in patients without acute coronary syndrome is rather complex, due to the lack of supportive data; also in the context of acute myocardial infarction PCI is associated with lower procedural success due to the high frequency of no-reflow and embolization phenomena. In our case, the heart team opted for surgical treatment due to the subocclusion of the proximal LAD and considering stable angina as admitting diagnosis, instead of acute coronary syndrome. Moreover the CAAs were placed in proximal segments, with large amount of thrombus, so related with high risk for complications if PCI was performed. Conclusion: CAAs represent a challenge for both interventional cardiologist and car- diac surgeon. A thorough multidisciplinary diagnostic classification, by means of Multimodality Imaging techniques is crucial to select the correct strategy of manage- ment and to ensure the best procedural and long-term result, avoiding unnecessary high-risk procedures.