giant aneurysm
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Abstract Aims Autosomal dominant polycystic kidney disease (ADPKD) is a monogenic disorder driven by mutation of one of two genes: PKD1, which codifies polycystin-1, and PKD2, which codifies polycystin-2. The mutated proteins determine the formation of multiple renal cysts with a consequent decline in kidney function eventually leading to end-stage renal disease (ESRD). In the last decades the cardiovascular complications of ADPKD are emerging as the leading cause of death, but coronary artery disease (CAD) remains to be an uncommon complication. Methods and results A 60-year-old male patient affected by ADPKD, in dialysis treatment for ESRD, was admitted in 2020 to our hospital for invasive coronary angiography (ICA), checking eligibility for kidney transplantation. He had a previous history of hypertension and chronic ischaemic cardiomyopathy. ICA performed in 2017 for unstable angina assessed ectasiant coronary arteries with diffuse atherosclerotic disease (Figure 1), determining significant stenosis of the proximal left anterior descending artery and proximal circumflex artery, treated with percutaneous coronary intervention (PCI). In 2020 was so repeated ICA, that evidenced a good result of the previous PCI, but pointed out a severe progression of ectasiant disease, which led to formation of giant aneurysm of the proximal tract of the right coronary artery, assessed at 3.8 cm × 2.5 cm (Figure 2), fistulizing to the right atrium and determining significant flow limitation in the following part of the right coronary artery. The absence of any symptoms and the lack of evidence of ongoing heart dysfunction, led our team to indicate conservative management and angiography follow-up. Conclusions Cardiovascular disease is a major cause of morbidity and death in ADPKD, underlying a tendency towards accelerated atherosclerosis, but wide data about coronary involvement are still lacking. ADPKD patients seem to have an increased risk of developing coronary aneurisms, but either due to the expression of mutated proteins in arterial smooth cells, to the accelerated atherosclerotic disease or to the combination of both, is still controversial. Consequently, it is difficult to differentiate the underlying pathophysiology of aneurysm formation in an individual patient and to speculate whether ADPKD patients have an increased risk of developing coronary aneurysms independent of their accelerated atherosclerotic process.

Giant coronary artery aneurysm is an uncommon disease, treated with surgical intervention or percutaneous coil embolization. A thrombosed aneurysm can cause extrinsic compression on the cardiac chambers, with potential hemodynamic effects and may cause problems when we need to implant a cardiac device. We present a case of difficult pacemaker implantation in a patient with 3 syncopes, first-degree AV block and complete left bundle branch block on electrocardiogram. The patient presented a giant aneurysm of the right coronary artery (85 x 90 mm), thrombosed, with right atrial compression. The pacemaker implantation was hampered by the difficulty of passing the lead through the compressed right atrium; indeed, only with   simultaneous echocardiographic and fluoroscopic guidance, was it possible to complete the procedure. This case demonstrates the utility of echocardiogram, in particular settings, in cardiac stimulation procedures.

A 70-year-old man presented to our hospital with non-ST elevation myocardial infarction and severely depressed left ventricular systolic function. Coronary angiogram revealed a giant fusiform aneurysm of the proximal left anterior descending artery with significant stenoses immediately proximal and distal to it and a left circumflex chronic total occlusion. The patient was treated surgically, with ligation and bypass of the aneurysm using a radial artery graft and a vein graft to the first obtuse marginal branch.

Objective Neuroendovascular procedures rely on successful navigation and stable access to the target vessel. The Stabilizer is a 300 cm long exchange wire with a 0.014 diameter and a soft, flexible stent at the distal end designed to assist with navigation and device delivery. This study aims to assess the efficacy of the Stabilizer for navigation in a variety of challenging environments. Methods The efficacy of the Stabilizer was evaluated using three challenging vascular models: a giant aneurysm model, a severe tortuosity model, and an M1 stenosis model. The Stabilizer was compared with a conventional wire during navigation in each model. Results In the giant aneurysm model, there was no significant difference of success during straightening of a looped wire and significantly higher success rates when advancing an intermediate catheter with the Stabilizer beyond the aneurysm neck compared to a conventional guidewire. The Stabilizer also significantly increased success rates when advancing an intermediate catheter through a model with severe tortuosity compared to a conventional guidewire, as well as exchange maneuver for intracranial stenting in a stenosis model compared to an exchange wire. Conclusions In our experimental model, the Stabilizer significantly improved navigation and device delivery in a variety of challenging settings compared to conventional wires.

Background: A 3-year-old girl presented with a 6-day history of severe headaches. On examination, upper motor neuron signs were noted in the left upper and lower extremities with increased tone, reflexes, and a positive Babinski sign. MRI of the brain revealed a giant right middle cerebral artery (MCA) aneurysm with significant mass effect, associated with cerebral edema and ventricular effacement. CT and CT angiogram showed evidence of aneurysmal wall calcification and lamellar thrombosis within the aneurysmal sac. In addition, there was a smaller right MCA aneurysm in close proximity to the giant aneurysm. Methods: After a balloon occlusion test to assess collateral blood flow to the MCA territory, it was decided to treat both aneurysms with a flow diverting stent. Dual antiplatelet loading was done with aspirin and clopidogrel. The smallest available diameter of Pipeline Shield stent was deployed. Results: The patient remained neurologically unchanged. Early follow-up imaging demonstrated stent patency, reduced size and mass effect of the large aneurysm, reduced cerebral edema, and no flow into the smaller aneurysm. Conclusions: Flow diversion stenting may be employed successfully in pediatric patients, though has unique technical considerations including small size vessels and limited evidence for antiplatelet agent choice and dosing.

Abstract Kawasaki disease is usually self-limited, but it can lead to aneurysm, stenosis, thrombosis, and myocardial infarction in the coronary arteries. The most important complication of Kawasaki disease is coronary artery aneurysm. Coronary artery aneurysm or ectasia may be seen in 15–25% of patients who do not receive treatment. It develops in 5% of children who receive intravenous immunoglobulin at the appropriate time. Acute myocardial infarction is the most important cause of morbidity and mortality in Kawasaki patients with giant aneurysms. We present a 10-year-old girl who had a history of giant aneurysm in the coronary arteries and underwent percutaneous coronary intervention due to anterior myocardial infarction.

BackgroundBasilar artery (BA) trunk aneurysms are rare, and the clinical characteristics and outcomes of endovascular treatment (EVT) remain unclear. The purpose of this study was to report clinical and angiographic outcomes of BA trunk aneurysm treated with EVT and to analyze risk factors for unfavorable outcomes.MethodsFrom October 2004 to December 2020, a total of 40 patients with BA trunk aneurysms underwent EVT. Clinical characteristics and outcomes were evaluated retrospectively from a prospectively collected database. Of the 40 enrolled patients, nine were treated by coiling without stents, 17 were treated by stent-assisted coiling, six by stent only, five by flow diverters, and three by vertebral artery occlusion.ResultsIn total, 27 (67.5%) patients had subarachnoid hemorrhage as an initial presentation, and 20 (50.0%) had large/giant aneurysms. Procedure-related complications occurred in five patients (12.5%); favorable clinical outcome was achieved in 27 patients (67.5%); and six patients (15.0%) died. Favorable angiographic outcome was achieved in 26 (83.9%) of 31 patients who underwent follow-up angiography. Poor initial Hunt-and-Hess grade (OR 7.67, 95% CI 1.55 to 37.80; p=0.018) was the only independent risk factor for unfavorable clinical outcome. Large/giant aneurysm (OR 8.14, 95% CI 1.88 to 27.46; p=0.047) and long lesion (OR 14.25, 95% CI 1.48 to 69.80; p=0.013) were independent risk factors for unfavorable angiographic outcomes during follow-up.ConclusionsEVT might be a feasible option for this rare disease entity. Unfavorable angiographic outcome might be expected in a large/giant aneurysm or a long lesion. It can be difficult to treat BA trunk aneurysms by EVT, needing multiple procedures or various techniques due to diverse clinical and angiographic features.