<div>Title: ST elevation myocardial infarction with right coronary aneurysm
successfully treated with a drug-coated balloon-only strategy</div><div>Word count: 493 words</div><div>First author: Yu Sugawara, MD</div><div>Department of Cardiology, Yamato-Kashihara Hospital, Japan</div><div>Corresponding author:</div><div>Yu Sugawara, MD</div><div>Department of Cardiology, Yamato-Kashihara Hospital</div><div>81, Ishikawa-cho, Kashihara-shi, Nara-ken, Japan 634-0045</div><div>Phone +81-744-27-1071</div><div>Fax: +81-744-27-4609</div><div>E-mail:
waegurorunsra@hotmail.co.jp</div><div>Key clinical message:</div><div>ST elevation myocardial infarction (STEMI) with a coronary aneurysm is
rare, thus its treatment is not established. This case suggested that
drug-coated balloon angioplasty may be considered for STEMI patients
with coronary aneurysms.</div><div>Text</div><div>The incidence of coronary aneurysm ranges from 0.3 to
5.3%.<sup>1</sup> ST-elevation myocardial infarction (STEMI)
with a coronary aneurysm is rare; hence, no standard therapy and
guidelines are established. Drug-coated balloons (DCBs) are innovative
devices used in treating STEMI and large vessels (diameters ≥3.0 mm),
allowing stent-less procedures with favorable
outcome.<sup>2, 3</sup></div><div>We report on a 60-year-old man with hypercholesterolemia hospitalized
for STEMI. His past history of Kawaski disease was unclear. Coronary
angiography (CAG) demonstrated that the left anterior descending artery
(LAD) was mildly ectatic, although no stenosis or occlusion in both LAD
and circumflex artery was observed. However, CAG revealed total
occlusion of the middle right coronary artery and circular calcified
structure (Fig. 1). Thus, urgent percutaneous coronary intervention
(PCI) was performed. A 6Fr Mach<sup>TM</sup>1 JR4.0 guiding
catheter (Boston Scientific, Marlborough, MA, USA) was placed and a
0.014-inch Sion Blue (Asahi Intecc, Akatsuki Cho, Japan) guidewire was
introduced. Following thrombus aspiration and dilatation with a
2.0×15-mm balloon (Ryurei®, Terumo, Aichi, Japan), we employed
intravascular ultrasound (IVUS) (OptiCross®, Boston Scientific,
Marlborough, MA, USA) (Fig. 2). IVUS revealed a coronary aneurysm and
180-degree calcification at the distal site, plaque, and thrombus at the
culprit site. The lumen diameter measured 2.45×2.87 mm, with a minimum
lumen area of 5.47 mm<sup>2</sup>. A 360-degree vessel wall
calcification was found at the proximal site, with a lesion length of
15.7 mm (Fig. 2 a-c). We obtained Thrombolysis In Myocardial Infarction
(TIMI) grade 2-3 flow. There were small amounts of coronary thrombi at
that time. Generally, drug-eluting stent implantation is considered for
patients with STEMI. However, this was decided against because IVUS
findings showed malapposition occurring in the follow-up period. In
terms of lesion restenosis in chronic phase, the DCB strategy is
superior to conventional plain old balloon angioplasty strategy.
Furthermore, the use of DCB for STEMI is safer than that of
2<sup>nd</sup> generation drug eluting stents in terms of
all-cause mortality and all adverse cardiac events.<sup>2</sup>Moreover, DCB may be an effective strategic choice in patients with
large, de novo coronary lesions.<sup>3</sup> Thus, a 3.0×20-mm
paclitaxel DCB (SeQuent Please NEO®, Nipro, Osaka, Japan) angioplasty
was performed following pre-dilatation with a 3.0×13-mm scoring balloon
(Lacrosse aperta NSE®, Nipro, Osaka, Japan) to reduce the risk of target
lesion failure. The final CAG revealed TIMI grade 3 flow (Fig. 3).
Cardiac coronary computed tomography (CT) following PCI showed a
saccular aneurysm with plaques and heavy calcification (Fig. 4). The
peak creatine kinase level was 1243 IU/L (normal range, 56-244 IU/L).
Echocardiography showed that the ejection fraction was 60% and that
cardiac wall motion was almost normal; unfortunately, a right coronary
aneurysm could not be detected. This patient was discharged 9 days after
admission, and aspirin and warfarin were prescribed in the chronic
phase.</div><div>STEMI with a coronary aneurysm is not common, and its management is
challenging. We evaluated the coronary aneurysm with multiple modalities
(CAG, IVUS and cardiac CT). DCB angioplasty may be considered for STEMI
patients with coronary aneurysms.</div><div>Key words: Cardiac computed tomography, Coronary aneurysm, Drug-coated
balloon, ST-elevation myocardial infarction</div><div>Author contribution</div><div>Yu Sugawara: Investigation and writing-original draft</div><div>Acknowledgements</div><div>None.</div><div>Author and funding disclosures:</div><div>Yu Sugawara</div><div>Funding: None.</div><div>Conflict of interest: The authors declare no conflicts of interest.</div><div>Consent</div><div>The author has obtained written informed consent from patient.</div><div>References</div><div>1. Abou Sherif S, Ozden Tok O, Taşköylü Ö, Goktekin O, Kilic ID.
Coronary artery aneurysms: A review of the epidemiology,
pathophysiology, diagnosis, and treatment. <i>Front Cardiovasc Med.</i> 2017;4:24.
doi.10.3389/fcvm.2017.00024</div><div>2. Merinopoulos I, Gunawardena T, Corballis N, Bhalraam U, Reinhold J,
Wickramarachchi U, et al. Assessment of paclitaxel drug-coated balloon
only angioplasty in STEMI. <i>JACC Cardiovasc Interv.</i> 2023;16:771–9.
doi.10.1016/j.jcin.2023.01.380</div><div>3. Sciahbasi A, Mazza TM, Pidone C, Samperi S, Cittadini E, Granatelli
A. A new frontier for drug-coated balloons: Treatment of “de novo”
stenosis in large vessel coronary artery disease. <i>J Clin Med.</i> 2024;13:1320.
doi.10.3390/jcm13051320</div><div>Figure legends</div><div>Figure 1. The left anterior descending artery (LAD) shows mildly
dilation but no stenosis in both the LAD and circumflex artery. The
right coronary angiography revealing occlusion (yellow arrow) and the
aneurysm’s silhouette (red arrows).</div><div>Figure 2. Each line indicating intravascular ultrasound (IVUS)
cross-sectional images.</div><div>a. At the distal site, IVUS showing an aneurysm and calcification.</div><div>b. Thrombus formation (white arrows) occurring at the culprit site, with
a lumen diameter of 2.45×2.87 mm and a minimum lumen area of 5.47
mm<sup>2</sup>.</div><div>c. The proximal site vessel exhibiting protrusion outward and 360-degree
vessel wall calcification.</div><div>Lesion measuring 15.7 mm in length (white line).</div><div>Figure 3. Final angiogram showing a Thrombolysis in Myocardial
Infarction grade 3 flow.</div><div>Figure 4. Cardiac CT demonstrating a saccular aneurysm (red arrows) with
plaque and severe calcification (yellow arrows).</div>