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Page 8 of 14 Barioli et al. Vessel Plus 2024;8:13 https://dx.doi.org/10.20517/2574-1209.2023.68

and stent malapposition. Combined use of thrombectomy and glycoprotein IIb/IIIa inhibitors is generally
[45]
recommended as adjunctive therapy to restore blood flow in acute coronary syndromes setting
[Figure 3]. For all these reasons, the procedure should be carefully planned according to clinical
presentation, etiology, location, and size of the aneurysm, and possible association with obstructive CAD.

When balloon-expandable stents are used to treat coronary stenoses in the proximity of an aneurysm,
special care should be taken in selecting a stent with a length strictly limited to the stenotic segment, to
avoid landing in the aneurysm and reduce the risk of struts malapposition. The use of self-expanding
coronary stents was also reported to be safe and effective in patients with CAE or tapered segments, given
the ability of self-apposing devices to adjust to varying lumen diameters [46-48] . Off-label treatment of CAAs
[49]
with self-expanding carotid artery stents has also been proposed .

Different percutaneous strategies are available if the primary goal of the PCI is the complete exclusion of the
aneurysmal sac. Covered stent implantation should be considered when treating saccular aneurysms or
pseudoaneurysms that do not involve a major side branch [Figure 4]. However, covered stents are bulky,
[50]
not flexible, and thus may not be easy to deliver in tortuous and calcified vessels. In addition, some of them
require large guiding catheters or introducer sheaths to be delivered. The most widely used covered stents
are the GRAFTMASTER (Abbott Vascular, Santa Clara, California), the PK Papyrus (Biotronik, Berlin,
Germany), and the 5F compatible BeGraft Coronary Stent Graft System (Bentley Innomed, Hechingen,
Germany).

In the case of large aneurysms complicated by coronary thrombosis, the “stove-pipe technique”, which
involves the delivery of multiple overlapping covered stents within the aneurysm and post-dilation at
proximal and distal landing zones, has also been described .
[51]

An alternative strategy is the so-called “double stent method”, which consists of implanting a non-covered
stent within another, with the aim of reducing stent permeability and promoting aneurysm thrombosis,
[52]
while preventing the delayed endothelization observed after covered stent implantation .

When the previous techniques cannot be used due to tortuosity, calcifications, or fear of side branch
occlusion, the stent-assisted coil embolization technique can be used. This technique involves the placement
of a microcatheter inside the aneurysm over a floppy 0.14" guidewire. A drug-eluting stent is advanced over
a second guidewire and deployed in the main vessel, jailing the microcatheter between the stent struts and
the artery. Multiple coils are then delivered through the microcatheter inside the aneurysm. After
angiographic confirmation of successful coil embolization of the aneurysm, the microcatheter is retrieved
and the stent can be finally post-dilated [53-55] .

In patients presenting with large CAAs, such as those originating from saphenous vein grafts, percutaneous
closure with Amplatzer vascular plugs seems an attractive alternative to surgery when the affected graft
supplies a small myocardial territory [14,56,57] .

We performed an extensive search using online literature databases to identify all the available studies
reporting the outcomes of patients with CAAs and CAE undergoing PCI. In particular, MEDLINE
(PubMed), Google Scholar, and ClinicalTrials.org were searched using a combination of Boolean operators
(“OR”, “AND”) for key terms including “Coronary artery ectasia”, “Coronary artery aneurysm”,
“Percutaneous management”, and “Outcomes”. We included all the studies published from 1991 to May
2023. Data are shown in Table 2.