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\begin{document}

\title{Left main coronary artery aneurysm occlusion presenting as myocardial
infarction with cardiogenic shock: Patient saved by securing left
anterior descending artery at cost the of other vessels}



\author[1]{sharad Chandra }%
\author[1]{RAJEEV CHOUDHARY}%
\author[1]{Ayush  Shukla}%
\author[1]{Gaurav  Chaudhary}%
\affil[1]{King George's Medical University Department of Cardiology}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Coronary artery aneurysms and ST-segment elevation myocardial infarction
(STEMI) are seldom encountered in clinical practice and pose a
management challenge. We describe the case of a patient diagnosed with
anterior wall myocardial infarction with a complete occluded left main
coronary artery (LMCA). After the establishment of partial blood flow
within the%
\end{abstract}%



\sloppy


\textbf{Type of manuscript:} Case Report

\textbf{Title:} Left main coronary artery aneurysm occlusion presenting
as myocardial infarction with cardiogenic shock: Patient saved by
securing left anterior descending artery at cost the of other vessels

\textbf{Short title:} LMCA occlusion presenting as STEMI

\textbf{Author details}

Sharad Chandra, M.D., D.M.\textsuperscript{a}, Rajeev Krishna Choudhary,
M.D., D.M.\textsuperscript{b}, Ayush Shukla, M.D.,
D.M.\textsuperscript{c}, Gaurav Chaudhary, M.D., D.M.\textsuperscript{d}

\textbf{Institutional Affiliations}

\textsuperscript{a} Professor, Department of Cardiology, King George's
Medical University, Lucknow, Uttar Pradesh -- 226003, India, (email id:
sharadaiims@gmail.com)

\textsuperscript{b} Assistant Professor, Department of Cardiology, King
George's Medical University, Lucknow, Uttar Pradesh -- 226003, India,
(email id: rajeevsjh@gmail.com)

\textsuperscript{c} Assistant Professor, Department of Cardiology, King
George's Medical University, Lucknow, Uttar Pradesh -- 226003, India,
(email id: ayushgeorgian@gmail.com)

\textsuperscript{d} Professor, Department of Cardiology, King George's
Medical University, Lucknow, Uttar Pradesh -- 226003, India, (email id:
gauravchaudharydr@gmail.com)

\textbf{The institution at which the work was performed:}

Department of Cardiology, King George's Medical University,

Lucknow, Uttar Pradesh-- 226003, India

\textbf{Address for all correspondence, including e-mail address} :

Dr. Sharad Chandra, MD, DM

Department of Cardiology,

King George's Medical University,

Lucknow, Uttar Pradesh-- 226003, India

\textbf{Phone:} +91 9936001168

\textbf{E-mail} : : sharadaiims@gmail.com

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy.

\textbf{FUNDING}

Nil.

\textbf{CONFLICT OF INTEREST}

The authors declare no conflict of interest.

\textbf{CONSENT STATEMENT}

Consent was obtained from the patient's wife as he underwent urgent PCI.





\textbf{ABSTRACT}

Coronary artery aneurysms and ST-segment elevation myocardial infarction
(STEMI) are seldom encountered in clinical practice and pose a
management challenge. We describe the case of a patient diagnosed with
anterior wall myocardial infarction with a complete occluded left main
coronary artery (LMCA). After the establishment of partial blood flow
within the LMCA was achieved, a 6 x10 mm aneurysm was discovered in the
LMCA. To the best of our knowledge, this case appears to be the first
successful percutaneous treatment of a completely obstructed aneurysmal
LMCA.

\textbf{Keywords:} coronary artery aneurysm; left main coronary artery,
ST-segment elevation myocardial infarction, stent



\textbf{INTRODUCTION}

It is unusual for a ST-elevation myocardial infarction (STEMI) to be
caused by a left main coronary artery (LMCA) aneurysm {[}1{]}. The
pathogenesis of STEMI in aneurysms is perplexing, and its therapy is
still debatable. Case studies have been used primarily to describe
pharmacological therapy, percutaneous coronary intervention (PCI),
coronary artery bypass grafting (CABG), and hybrid approaches depending
on the severity of coexisting coronary artery stenosis.

\textbf{CASE REPORT}

A 40-year-old male smoker and tobacco chewer presented to the emergency
department eight hours after onset of resting angina. The patient's
history was unremarkable without any record of similar symptoms
experienced earlier. He also did not have a family history of ischemic
heart disease. His physical examination revealed a heart rate of 116
beats/min, blood pressure of 90/66 mmHg, respiratory rate of 20
breaths/min, and oxygen saturation (SPO\textsubscript{2}) of 88\%.
Electrocardiography showed ST elevation in V2-V6, I, and aVL, suggestive
of anterior wall myocardial infarction (AWMI). During hospitalization,
the patient developed hemodynamically unstable ventricular tachycardia
(VT) which was treated with DC cardioversion. The patient was
immediately rushed to the cath-lab for primary PCI.

After engaging the LMCA with a 6F EBU 3.5 Launcher guiding catheter
(Medtronic Inc, Minneapolis, USA) an occlusion within the LMCA was
encountered. Initial considerations included the possibility of a
dissection induced by the guide catheter or a complete thrombotic
occlusion of the LMCA, given the absence of observable branches or
distal vasculature beyond this occlusion point \textbf{(Fig 1. \& Video
1)} . Due to complaints of persistent chest pain by the patient,
cautious advancement of the workhorse guide wire was performed, leading
to an extension of staining. Finally, the lesion was crossed using a
Fielder FC guidewire (polymer jacket and hydrophilic wire, Asahi Intecc,
Aichi, Japan) originally intended for wiring the left anterior
descending artery (LAD) and achieving some flow \textbf{(Fig. 2)} , but
ultimately went into a diagonal branch \textbf{(Video 2)} . As the
thrombosuction catheter was unable to cross, the LMCA lesion was
pre-dilated with a 2 x 10 mm semi-compliant balloon.

After establishment of partial blood flow within the LMCA \textbf{(Fig.
2)} , a 6 x10 mm aneurysm was discovered in the LMCA \textbf{(Fig. 3 \&
Video 3)} . The case was discussed with among the cardiothoracic
surgical team. The decision was made to pursue revascularization using
PCI. Two other Fielder FC wires were introduced into both the LAD and
the ramus intermedius (RI). Dilation of the RI was also performed with a
2 x 10 mm semi-compliant balloon\textbf{(} \textbf{Fig. 4 \& Video 4)}
While both LAD and RI achieved thrombolysis in myocardial infarction
(TIMI) grade I flow, efforts to wire the left circumflex artery (LCx)
were unsuccessful \textbf{(Video 5)} . Consequently, a decision was made
to employ a 5F TIG diagnostic catheter (Terumo Corporation, Shibuya -Ku,
Tokyo) to perform an angiogram of the right coronary artery (RCA)s via
the radial route. This imaging revealed the RCA was normal, however, a
grade 3 retrograde collateral circulation was evident from the RCA to
the LCx, suggestive of LCx chronic total occlusion (CTO) \textbf{(Fig. 5
\& Video 6)} .

Our intended approach involved the placement of a covered stent in the
LM-LAD. However, due to the delayed availability of the designated stent
and the patient's compromised hemodynamic state, a 3.5 x 20 mm Promus
Elite stent (Everolimus Eluting Platinum Chromium Coronary Stent System,
Boston Scientific Corporation, Marlborough, USA) was deployed from LMCA
to LAD \textbf{(Fig. 6 \& Video 7)} . Subsequent to stent implantation a
4 x 10 non-compliant balloon was employed for post-dilatation. This
yielded improved blood flow in the LAD and diagonal. Notably, on
intravascular ultrasound (IVUS) imaging, the LM aneurysm was visualized
as a radiolucent shadow with layers and scintillating blood shadow
surrounding the stent struts and the stent appeared to dangle, creating
a potential nidus for thrombus formation \textbf{(Fig. 7 \& Video 8)} .~
In an endeavor to exclude the aneurysm, a 3.8 x 26 mm Graftmaster
covered stent (Coronary Stent Graft System, Abbott Vascular, Santaclara,
USA) was subsequently deployed from ostial LMCA, encompassing the LCx
and small sized RI extending up to the LAD/diagonal
bifurcation,\textbf{(Video 9)} and post-dilated with a 5 x 8 mm
non-compliant balloon.

Finally, TIMI II flow in both LAD and diagonal was achieved\textbf{(Fig.
8 \& Video 10).} Post procedure IVUS revealed bright echo reflection due
to the covered stent and echo drop out was observed behind the multiple
layers of stents \textbf{(Fig. 9 \& Video 11)} . The patient was
discharged on aspirin, clopidrogrel, rivoraxaban and high dose statin.
At 3-month follow-up, angiography revealed TIMI III flow into the LAD
and its branches \textbf{(Fig. 10 \& Video 12)} and complete
obliteration of the aneurysm. The patient's symptoms improved, and he
was symptomatically better.

\textbf{DISCUSSION}

The term ''coronary artery aneurysms'' (CAAs) refers to localized
irreversible dilatation of a coronary artery to a diameter more than 1.5
times that of the adjacent normal coronary segments. In contrast,
coronary artery ectasias (CAE) occur as widespread arterial dilations
wherein the length of the dilated segment is more than 50\% of the
diameter {[}2, 3{]}. Morgagni published the first pathological
description of a coronary artery aneurysm {[}2{]}. With the advanced
application of coronary tomography (CT) and invasive coronary
angiography, an anticipated increase in detection rate of CAAs exists.

Although the exact prevalence of CAAs is difficult to determine due to
their asymptomatic nature, it is likely underestimated -- reported
prevalence ranges from 0.3--5\%. RCA is most affected (40--70\%),
followed by the LAD (32.3\%) and LCx (23.4\%) {[}3, 4,{]}. An aneurysm
in the left main coronary artery aneurysm (LMCAA) is a very rare finding
occurring in 0.1\% cases as reported by Topaz et al. {[}5{]}. A review
recently published identifies atherosclerosis (40\%) as the most common
cause of LMCAAs, followed by inflammatory (12\%) and congenital (9\%)
factors. Compared to stable angina (43\%) and acute coronary syndromes
(ACS) (32\%), which were more often the first clinical signs, 14\% of
LMCAA were incidental observations. 18.6\% of the patients were
presented as STEMI {[}6{]}.

Atherosclerosis is the leading cause of CAAs, accounting for
approximately half of the cases. Other potential causes include
vasculitis (Kawasaki disease and Takayasu arteritis), infections
(bacterial, fungal, mycobacterial, Lyme, syphilitic, septic emboli,
mycotic aneurysm, and HIV), connective tissue disorders (Marfan syndrome
and Ehlers-Danlos syndrome), congenital conditions, fibromuscular
dysplasia, and traumatic (post PCI).

While most patients are asymptomatic and are diagnosed incidentally,
symptomatic patients often present with either effort angina or ACS
owing to concurrent obstructive atherosclerotic disease or local
thrombosis and embolisation {[}7, 8{]}. Rarely, it can present as
cardiac tamponade due to CAA rupture or symptoms due to compression of
adjacent structures. LMCAAs might even manifest as an incidental
anterior mediastinal mass and syncope {[}9, 10{]}. Occasionally, a
systolic murmur can be detected over the precordial region {[}3{]}.

The most effective diagnostic approach for CAAs likely involves coronary
angiography coupled with IVUS. IVUS can help address drawbacks such as
underestimation of CAA size due to intraluminal thrombi and
differentiation between true and false aneurysms. Transthoracic
echocardiography (TTE) is particularly helpful in the detection of
abnormalities in the proximal LMCA and RCA, especially in children with
Kawasaki disease. Computed tomography (CT) angiography is valuable for
assessing larger CAAs and those with saphenous vein graft aneurysm.
Optical coherence tomography (OCT) has limitations due to its narrow
scanning diameter. OCT capabilities are constrained by the infrared
scan's narrow diameter {[}7, 8{]}.

Given the rarity of this cardiac entity and the lack of standard
treatment guidelines, management approaches typically involve
anticoagulation-based medical therapy, stenting using covered stents, or
surgical intervention. Treatment decisions should be tailored to patient
characteristics, clinical presentation, and the location and morphology
of the aneurysms. According to a recent review, 53\% of LMCAA patients
received surgical treatment, while only 7\% received percutaneous
intervention. CAAs, especially LMCAAs, are associated with poor
prognosis, with a reported 15\% mortality rate after a median 8-month
follow-up, when longitudinal data (n = 81) were reported for LMCAA
{[}6{]}

In the present case, as the patient suffered an acute AWMI with a
completely occluded LMCA, it was decided to assess the anatomy of the
LAD and LCx and then pursue revascularization. A planned approach to
cross the lesion and wire the LAD resulted in inadvertent wiring of the
diagonal artery. After discovering the LMCA aneurysm after pre-dilation,
another wire was placed in the LAD and RI, however wiring and
visualization of LCx proved unsuccessful. Consequent RCA angiography
revealed complete LCx occlusion, filling retrogradely through the RCA.
It was decided to stent LM-LAD up to LAD and the Diagonal bifurcation
with a covered stent. Drug-eluting stents in such a LMCA aneurysm have a
high chance of stent thrombosis. At the three-month follow-up, the
patient's symptoms improved, and angiography revealed TIMI III flow and
aneurysm completely obliterated. To the best of our knowledge, this case
appears to be the first successful percutaneous treatment of a
completely obstructed aneurysmal LMCA.

\textbf{CONCLUSION}

LMCAAs can arise due to a variety of factors, the specific underlying
cause in the present patient is most likely atherosclerosis. Treatment
options typically encompass anticoagulation to mitigate the risks
associated with thrombus formation, and surgical intervention is often
the preferred approach. However, in the case of ACS, PCI becomes a
viable choice if emergency bypass grafting is not feasible.
Nevertheless, if the LM is implicated, a hybrid approach may be
considered, especially if all vessels are unable to receive a bypass
graft.

\textbf{REFERENCES}

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\item
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\item
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\end{enumerate}



\textbf{FIGURE LEGENDS}

\textbf{Fig 1:} Complete thrombotic occlusion of the left main coronary
artery

\textbf{Fig 2:} Some flow restoration after diagonal wiring

\textbf{Fig 3:} Post pre-dilation and wiring of the diagonal and left
anterior descending artery

\textbf{Fig 4:} Ramus intermedius wired with Fielder FC and balloon
dilatation performed to achieve thrombolysis in myocardial infarction I
flow

\textbf{Fig 5:} Chronic total occlusion of the left circumflex artery
filling retrogradely from the right coronary artery

\textbf{Fig 6:} A 3.5 x 20 mm drug-eluting stent placed in left
main-left anterior descending artery and post dilated with a non
compliant balloon

\textbf{Fig 7:} Intravascular ultrasound showing aneurysm around stent

\textbf{Fig 8:} Thrombolysis in myocardial infarction II flow achieved
post 3.8 x 26 mm Covered stent deployment and dilation by 5x8 mm non
compiant balloon

\textbf{Fig 9:} Intravascular ultrasound post covered stent

\textbf{Fig 10:} 3-month follow up angiography showing thrombolysis in
myocardial infarction III flow



\textbf{VIDEO LEGENDS}

\textbf{Video 1:} Occluded left main coronary artery

\textbf{Video 2:} Crossing of wire across left main coronary artery

\textbf{Video 3:} Appearance of left main coronary artery aneurysm

\textbf{Video 4:} Diagnoal, left anterior descending artery and ramus
wired and ramus dilated with semi compliant balloon

\textbf{Video 5:} Thrombolysis in myocardial infarction I flow achieved
in left anterior descending artery, diagonal, and ramus

\textbf{Video 6:} Left circumflex artery 100\% chronic total occlusion
filling retrogradely from right coronary artery

\textbf{Video 7:} Drug-eluting stent placed in left main-left anterior
descending artery

\textbf{Video 8:} Intravascular ultrasound showing left main aneurysm
around the stent

\textbf{Video 9:} Covered stent deployment

\textbf{Video 10:} Final angiogram after covered stent

\textbf{Video 11} : Intravascular ultrasound post covered stent

\textbf{Video 12:} Thrombolysis in myocardial infarction III flow
oberved at 3-month follow-up\selectlanguage{english}
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