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\begin{document}

\title{An unpleasant tenant -- a conundrum in an emergency}



\author[1]{Abraham Paul}%
\affil[1]{Apollo Adlux Hospital}%


\vspace{-1em}



  
  \date{May 15, 2024}


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\selectlanguage{english}
\begin{abstract}
A 60yr old hypertensive patient presented with inferior wall myocardial
infarction. His coronary angiogram showed ectatic coronaries, with a
large thrombus in an aneurysmally dilated right coronary artery.
Emergency coronary artery bypass grafting was performed, and he was
discharged on the seventh post operative day.%
\end{abstract}%



\sloppy


\textbf{An unpleasant tenant -- a conundrum in an emergency}

\textbf{Key words -} intracoronary thrombus, aneurismal coronary artery,
inferior wall myocardial infarction

\textbf{History}

A 60yr old male, hypertensive, presented with chest pain. ECG showed
inferior wall myocardial infarction with complete heart block,
corroborated by echocardiography which also showed right ventricular
dysfunction. He was taken up for Primary PTCA under temporary pacing.

CAG showed ectatic left sided vessels with slow flow (figure 1, 2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\end{figure}

Figure 1. ectatic Left Anterior Descending Artery\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2. Ectatic Left Circumflex Artery

Right coronary injection revealed a large proximal aneurysm with
organized thrombus completely occluding the vessel.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure . Right Coronary Artery injection showing organized thrombus in
proximal aneurysm

Attempts were made to cross the occluded segment, however aggressive
manipulation was deferred due to fear of proximal dislodgement and
subsequent cerebral embolism. He developed ventricular fibrillation
thrice inside the cath lab, which was reverted with DC shock. He was
taken up for emergency Coronary Artery Bypass Grafting. Post surgery he
was noted to have left hemiparesis, and a CT brain confirmed right
frontal lobe acute infarct. He maintained sinus rhythm after surgery,
and was discharged 7 days after index event, on dual anitplatelets and
warfarin.

\textbf{Discussion}

Coronary artery aneurysm is a rare disorder, which occurs in
0.3\%--4.9\% of patients undergoing coronary
angiography\textsuperscript{1}. Atherosclerosis accounts for
\textgreater{}90\% of coronary artery aneurysms in adults, whereas
Kawasaki disease is responsible for most cases in
children\textsuperscript{2}. With the advent of implantation of
drug-eluting stents, there are increasing reports suggesting stents
causing coronary aneurysms, months or years after the
procedure\textsuperscript{3}.

Optimal management strategy has to be individualized using a combination
of the size of the aneurysm, expansion history, pathophysiology, and
symptoms to decide on intervention. The available percutaneous options
include conventional stent implantation, coil embolization, autologous
saphenous vein-covered stent grafting, and polytetrafluoroethylene
(PTFE)-covered stent graft\textsuperscript{4}. Surgical strategies
including resection, aneurysm ligation, marsupialization with
interposition graft, and coronary artery bypass surgery.

The indications for the surgical treatment of CAA in general are:

\begin{itemize}
\tightlist
\item
  Severe coronary artery disease
\item
  CAAs near the bifurcation of large branches
\item
  Evidence of emboli from the aneurysm to the distal coronary bed
  resulting in myocardial ischemia
\item
  Progressive enlargement of a CAA documented by serial angiographic
  measurements; and
\item
  CAAs in the LMS
\item
  Complications such as fistula formation
\item
  Compression of cardiac chambers
\item
  Giant CAA (dilatation exceeding the reference vessel diameter by
  \textgreater{} four times).
\end{itemize}

The prognosis of CAA depends on the size of the aneurysm. In general,
small aneurysms have a favorable prognosis with a low risk of myocardial
ischemic events and/or mortality. On the contrary, giant CAAs (i.e.,
those with an internal diameter \textgreater{}8 mm) have a high risk of
morbidity and mortality. About one-half of such aneurysms become
obstructed, and are associated with myocardial infarction, arrhythmias,
or sudden death.

\textbf{Authors contribution}

Dr Abraham Paul, corresponding author

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Aneurysmal coronary artery disease. \emph{Swaye PS, Fisher LD, Litwin
  P, Vignola PA, Judkins MP, Kemp HG, Mudd JG, Gosselin AJ Circulation.
  1983 Jan; 67(1):134-8.}
\item
  Coronary artery aneurysms and ectasia: role of coronary CT
  angiography. \selectlanguage{ngerman}\emph{Díaz-Zamudio M, Bacilio-Pérez U, Herrera-Zarza MC,
  Meave-González A, Alexanderson-Rosas E, Zambrana-Balta GF,
  Kimura-Hayama ET Radiographics. 2009 Nov; 29(7):1939-54.}
\item
  Coronary artery aneurysms after drug-eluting stent
  implantation.\emph{Aoki J, Kirtane A, Leon MB, Dangas G JACC
  Cardiovasc Interv. 2008 Feb; 1(1):14-21.}
\item
  Use of polytetrafluoroethylene-covered stent for treatment of coronary
  artery aneurysm. \emph{Szalat A, Durst R, Cohen A, Lotan C Catheter
  Cardiovasc Interv. 2005 Oct; 66(2):203-8.}
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/RCA/RCA}

\end{center}
\end{figure}

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