The incidence, angiographic features and natural history of discrete atherosclerotic coronary aneurysms were evaluated in 20 patients with 22 aneurysms (0.2% of 8,422 patients referred for coronary angiography). Fifteen aneurysms (68%) were in the left anterior descending, four (18%) in the circumflex, two (9%) in the right and one (5%) in the left main coronary artery. Aneurysm diameter ranged from 4 to 35 mm (mean 8); 95% of aneurysms were adjacent to a severe obstruction.Seventy-five percent of patients had severe triple vessel disease that included severe left main disease in 15%. Total obstruction of one or two arteries was present in 75%. In patients with wall motion abnormalities, 78% of the abnormalities were in the distribution of the aneurysm. Follow-up (range 1 to 90 months [mean 30]) was obtained in all 20 patients. There were two cardiac and two noncardiac deaths; 12 patients had coronary bypass surgery and of 16 survivors, 13 were angina-free.In conclusion, discrete coronary aneurysms are much less common than diffuse ectasia. Unlike ectasia, they are never found in arteries without severe stenosis, and are most common in the left anterior descending coronary artery. Associated coronary artery disease is more severe in patients with discrete aneurysms than in those with diffuse ectasia. Discrete coronary aneurysms do not appear to rupture, and their resection is not warranted

Glassman, Ephraim

Kronzon, Itzhak

Slater, James

Tunick, Paul A.

Elsevier - Publisher Connector 

Discrete atherosclerotic coronary artery aneurysms: A study of 20 patients 

JACC Vol. 15, No.2
February 1990:279-82
Discrete Atherosclerotic Coronary Artery Aneurysms:
A Study of 20 Patients
279
PAUL A. TUNICK, MD, FACC, JAMES SLATER, MD, FACC, ITZHAK KRONZON, MD, FACC,
EPHRAIM GLASSMAN, MD, FACC
New York, New York
The incidence, angiographic features and natural history of
discrete atherosclerotic coronary aneurysms were evalu-
ated in 20 patients with 22 aneurysms (0.2% of 8,422
patients referred for coronary angiography). Fifteen aneu-
rysms (68%) were in the left anterior descending, four
(18%) in the circumflex, two (9%) in the right and one (5%)
in the left main coronary artery. Aneurysm diameter
ranged from 4to 35 mm (mean 8); 95% of aneurysms were
adjacent to a severe obstruction.
Seventy-five percent of patients had severe triple vessel
disease that included severe left main disease in 15%. Total
obstruction of one or two arteries was present in 75%. In
patients with wall motion abnormalities, 78% of the abnor-
malities were in the distribution of the aneurysm. Follow-
The incidence and significance of aneurysmal disease of the
coronary arteries have been subjects for debate. The re-
ported incidence has ranged from 0.3% (1) to 4.9% (2) among
patients undergoing coronary angiography for coronary ar-
tery disease. Management recommendations have differed,
with one group (3) recommending repair of the aneurysm
because of the propensity for rupture and thrombosis, and
another (2) finding no difference in survival among patients
with and without aneurysm and occlusive coronary artery
disease. The latter investigators (2) concluded that coronary
artery aneurysmal disease does not constitute a separate
clinical entity but, rather, is a variant of coronary athero-
sclerosis. These apparent discrepancies may result from the
varying definitions of coronary aneurysm employed.
We analyzed a group of 20 patients with 22 discrete,
localized aneurysms of the coronary arteries, as recognized
on coronary artery angiography.
From the Department of Medicine, New York University Medical Center,
New York, New York.
Manuscript received June 26, 1989; revised manuscript received Aug-
ust 23, 1989, accepted September 13, 1989.
Address for reprints: Paul A. Tunick, MD, 560 First Avenue, Suite 2E,
New York, New York 10016.
@1990 by the American College of Cardiology
up (range 1 to 90 months [mean 30]) was obtained in aU 20
patients. There were two cardiac and two noncardiac
deaths; 12 patients had coronary bypass surgery and of 16
survivors, 13 were angina-free.
In conclusion, discrete coronary aneurysms are much
less common than diffuse ectasia. Unlike ectasia, they are
never found in arteries without severe stenosis, and are
most common in the left anterior descending coronary
artery. Associated coronary artery disease is more severe in
patients with discrete aneurysms than in those with diffuse
ectasia. Discrete coronary aneurysms do not appear to
rupture, and their resection is not warranted.
(J Am CoIl CardioI1990;15:279-82)
Methods
Selection of patients. From July 1981 to February 1987,
8,422 patients who underwent coronary angiography at our
institution were found to have atherosclerotic coronary
artery disease. For the purposes of this study, only patients
with a discrete aneurysm were included for analysis. A
discrete aneurysm was defined as a localized abnormal
dilation of the coronary artery that is spherical or saccular
(Fig. 1).
Specifically excluded from analysis were patients with
fusiform aneurysms, defined elsewhere (4) as having a spin-
dle shape that may involve a large segment of the artery.
Such aneurysms have also been referred to as coronary
artery ectasia. Although patients with ectasia have been
grouped together with patients with discrete aneurysms in
previous reports (2,5), they were not included in our study.
We also excluded patients with luminal bulges or irregular-
ities that did not exceed 1.5 times the diameter of the nearest
adjacent normal segment.
Coronary angiography. The angiograms of all patients
with localized, discrete aneurysms were analyzed to deter-
mine the size of the aneurysm and the extent and severity of
associated coronary lesions. Lesions with 270% diameter
0735-10971901$3.50
280 TUNICK ET AL.
DISCRETE CORONARY ANEURYSMS
lACC Vol. 15. No.2
February 1990:279-82
A
Figure 1. Left coronary angiogram of two patients in the right
anterioroblique projection. A, Discrete aneurysm of the left anterior
descending coronary artery (arrow). B, Discrete aneurysm of the left
circumflex artery (arrow).
reduction were considered severe; this definition included
lesions of the left main coronary artery. Left ventricular
angiograms were reviewed to analyze regional wall motion.
Clinical follow-up was obtained on all 20 patients by
contacting the patient or the patient's physician.
Results
Clinical features. The clinical characteristics and coro-
nary anatomy of the patients are summarized in Table 1.
There were 20 patients with a localized coronary aneurysm;
15 patients were male and 5female. Their average age was 69
years (range 54 to 84). These 20 patients represented 0.2% of
the 8,422 patients with angiographically apparent coronary
artery disease during the study period.
Coronary aneurysms (Table 1). There were 22 aneurysms
in the 20 patients (2 patients had 2 aneurysms each). Fifteen
aneurysms (68%) were located in the left anterior descend-
ing, four (18%) in the left circumflex, two (9%) in the right,
and one (5%) in the left main coronary artery. The diameter
of the aneurysms ranged from 4 to 35 mm (average 8 mm).
One previously reported patient (6) had two large aneurysms
(25 and 35 mm). With exclusion of this patient, the average
aneurysm diameter was 6 mm.
Associated coronary lesions (Table 1). Overall, 15 (75%)
of the 20 patients had severe triple vessel disease, including
3 patients (15%) who also had severe obstruction of the left
main coronary artery. The remaining five patients (25%) had
double vessel disease, and none had single vessel disease.
Fifteen patients (75%) had total obstruction of one or two
coronary arteries, with four patients having two total ob-
structions. The discrete coronary aneurysm was directly
adjacent to a severe coronary stenosis in 21 (95%) of the 22
aneurysms. The aneurysms occurred before or after the
obstruction, and in one case between two obstructions. In no
case did an aneurysm occur in an artery that was free of
severe obstruction.
Left ventricular function (Table 1). Ten of the 20 patients
had normal left ventricular wall motion. One patient had
diffuse left ventricular hypokinesia (and was one of the two
patients with severe aortic stenosis). In seven of the nine
patients with one or more segmental wall motion abnormal-
ities, at least one abnormality occurred in the distribution of
the artery with the aneurysm. Four patients had one seg-
mental wall motion abnormality, four had two and one had
three such abnormalities.
Follow-up (Table 2). Follow-up obtained in all 20 pa-
tients, ranged from 1 to 90 months (mean 30). There were
four deaths, at I, 6, 12 and 33 months, respectively, after
angiography. One patient died of a myocardial infarction
related to a bleeding complication of angiography. The
second died suddenly during an episode of high fever and
urinary sepsis. The third died of uremia, and the fourth of
transfusion-related acquired immunodeficiency syndrome
(AIDS). Twelve patients (including two of the four who died)
underwent coronary artery bypass surgery shortly after
coronary angiography. In the total group, only 3 of the 16
surviving patients had angina at the time of follow-up; the
rest were asymptomatic.
Discussion
Discrete aneurysms versus ectasia. Coronary aneurysms
have been recognized since 1812 (7). Probably the most
common cause is Kawasaki disease (8). Other reported
causes include congenital anomalies, infections, syphilis and
systemic lupus erythematosus (8,9). Coronary ectasia due to
atherosclerotic disease has been reported in 2% (2) and 4.9%
(5) of patients; the latter incidence rate was observed in
20,087 patients enrolled in the Coronary Artery Surgery
Study (CASS) Registry. The 978 CASS patients with aneu-
lACC Vol. 15, No.2
February 1990:279-82
TUNICK ET AL.
DISCRETE CORONARY ANEURYSMS
281
Table 1. Summary of 20 Patients With a Coronary Aneurysm
Age (yr)
Severity of Coronary Stenosis
Case & Gender Aneurysm(s) L Main LAD LCx RCA Wall Motion History
1 7lM LAD, 7 mm Sev Sev Tot N Ang, 1 yr
2 54M LAD, 5 mm Sev Tot Sev N Ang, 20 yr
3 65F LAD,4mm Sev Sev Sev Tot N CABG, 8 yr
4 76F Lmain, 7 mm Sev Sev AW-A DOE, 3 yr, AS
5 66M LAD, 8 mm Sev Tot Tot IW-H MI, 23 yr
(marg) AW-H MI, 13 yr
Ang, 5 yr
6 84F LAD, 7 mm Sev Sev DH CHF, AS
7 61M LAD,7mm Sev Sev N DOE,4mo
8 66M LAD, 7 mm Sev Sev Tot N Ang, 3 yr
(ramus)
9 17M LAD, 4 mm Tot Sev Tot IW-H MI, 5 mo
AX-H
10 75F LAD, 5 mm Sev Sev Sev Tot IW-D Ang, 3 yr
LAD, 7 mm AW-H
It 78M LCx,8 mm Sev Sev Tot N Ang, 2 yr
12 80M LAD,8mm Sev Sev Sev Sev N MI, It yr
Ang, 11 yr
13 12M LAD, 8 mm Sev Mod Tot N Ang, 4 yr
14 54M LAD, 4 mm Sev Sev Tot AW-A MI, It yr
VF, 6 mo
15 68M LCx, 6 mm Tot Sev Sev AW-H Ang, 10 yr
16 66M LCx, 4 mm Sev Sev Sev N MI, 1 yr
17 69M LAD, 5 mm Sev Tot Tot IW-H Uremia, new ang
(marg) AW-H
18 73M LCx, 13 mm Tot Sev Sev IW-D MI x 2, 3 yr
AX-H Ang, 3 yr
AW-D
19 60F RCA,4mm Sev Tot N Ang, 10 yr
20 73M LAD, 35 mm Tot Tot Sev AW-H Ang, 1 yr
RCA, 25 mm (Marg) AAA
A = akinetic; AAA = abdominal aortic aneurysm; Ang = angina, AS = aortic stenosis; AW = anterior wall; AX = apex; CABG = coronary artery bypass
graft; CHF = congestive heart failure; D = dyskinetic; DH = diffuse hypokinesis; DOE = dyspnea on exertion; F = female; H = hypokinetic; IW = inferiot
wall; LAD = left anterior descending coronary artery; LCx = left circumflex artery; L-main = left main coronary artery; M = male; Marg = marginal;
MI = myocardial infarction; Mod = moderate; N = normal; RCA = right coronary artery; Sev = severe; Tot = total occlusion; VF = ventricular fibrillation.
rysmal disease included those with fusiform disease or
diffuse ectasia. An illustrated saccular aneurysm in that
report (5) occurs in an artery that also demonstrates diffuse
ectasia, whereas all of our discrete aneurysms occurred in
arteries that were otherwise of normal or smaller than
normal caliber and that did not demonstrate diffuse widen-
ing. Ninety of the CASS patients had aneurysmal disease in
an artery without severe stenosis (no stenosis in 21 and
<70% stenosis in 69). In contrast, in all of our patients the
aneurysm occurred in an artery with severe or total obstruc-
tion.
There are two further distinctions between patients with
discrete aneurysms and those with ectasia. Aneurysmal
disease in the CASS Registry patients (5) was found most
frequently in the right coronary artery, whereas 68% of the
aneurysms in our study were in the left anterior descending
artery, and only two aneurysms (9%) were in the right
coronary artery. In addition, although among CASS Registry
patients triple vessel disease was more common in those
with than in those without aneurysmal disease (42% versus
34%), the severity of associated coronary disease was
greater in our patients with discrete aneurysms. Seventy-five
percent of our patients had severe triple vessel disease;
furthermore, 15% had severe left main stenosis and 75% had
total coronary occlusion.
Follow-up. Despite the severe occlusive disease present
in our patients, the follow-up data do not indicate a grave
prognosis. This finding probably reflects at least in part the
efficacy of both medical and surgical therapy. In fact, no
patient died directly as a complication of the aneurysm
during the follow-up period, and there was no incidence of
cardiac tamponade or even unexplained sudden death that
could have been due to rupture of the aneurysm. Further-
more, no thrombus was visualized in the aneurysms during
282 TUNICK ET AL.
DISCRETE CORONARY ANEURYSMS
JACC Vol. 15, No.2
February 1990:279-82
Table 2. Follow-Up Data in 20 Patients
Age (yr) Current Months of
Case & Gender CABG Angina Follow-Up Status
I 71M Yes No 90 A&W
2 54M No No 66 A&W
3 65F Yes Yes 55 A, mod. angina
4 76F Yes 33 Died, AIDS
5 66M Yes No 45 A&W
6 84F Yes No 41 A&W
7 61M No No 40 A&W
8 66M Yes No 36 A&W
9 17M Yes No 33 A&W
10 75F Yes No 32 A&W
11 78M No I Died, MI post-cath
12 80M No No 31 A&W
13 72M No No 6 A&W
14 54M No 6 Died, sudden
urinary sepsis
15 68M No Mod 23 A, symptomatic
16 66M Yes No 12 Died, uremia
17 69M No 16 A&W
18 73M Yes No 16 A&W
19 60F Yes Mod 11 A, symptomatic
20 73M Yes No 4 A&W
A = alive; A & W = alive and well with no angina; AIDS = acquired
immunodeficiency syndrome; post-cath = after cardiac catherization (bleed-
ing episode). Other abbreviations as in Table 1.
angiography. Infarction of areas in the distribution of the
aneurysm did occur, but wall motion abnormalities were not
seen in the distribution ofthe aneurysm in 50% ofthe patients.
Therefore, although no statement can be made about the
incidence of distal embolization from the discrete aneurysms,
associated coronary stenosis and occlusion were present to a
sufficient degree to account for the incidence of infarction.
Conclusions. Discrete atherosclerotic coronary aneu-
rysms are rare and occur much less commonly than diffuse
coronary ectasia. Unlike ectasia, they never occur in arteries
that do not have a severe stenosis and they occur most
commonly in the left anterior descending artery (rarely in the
right coronary artery). Furthermore, associated coronary
disease is more severe than in patients with diffuse ectasia.
Discrete atherosclerotic coronary aneurysms do not rupture,
and their resection is not warranted.
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Discrete atherosclerotic coronary artery aneurysms: A study of 20 patients

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