Ann Thorac Surg 1996;61:1247-1249
© 1996 The Society of Thoracic Surgeons
Case Report
Repair of an Aneurysm of the Left Main Coronary Artery
Martti Lepojärvi, MD,
Esa Salmela, MD,
Heikki Huikuri, MD,
Pentti Kärkölä, MD
Departments of Cardiothoracic Surgery and Cardiology, Oulu University Hospital, Oulu, Finland
Accepted for publication September 26, 1995.
 |
Abstract
|
|---|
Coronary artery aneurysms are rare, especially in the left main coronary artery. Coronary artery aneurysms may rupture or cause myocardial infarction. There are only a few reports of coronary artery aneurysms of the left main coronary artery treated surgically. We report a case in which an arterial graft from the internal iliac (hypogastric) artery was used for the reconstruction of a congenital coronary artery aneurysm of the left main coronary artery. After a follow-up of 5 years, the patient is well and in good condition.
|
Introduction
|
|---|
Aneurysmatic dilatation of the coronary arteries is a rather uncommon finding, as its prevalence in coronary angiograms is 0.15% to 4.9% [1]. Aneurysms of the main stem of the left coronary artery (LMA) are even less common. No such aneurysms could be identified in the series of 1,200 coronary artery aneurysms (CAAs) reported by Swaye and associates [1]. In the series of 22,000 catheterizations by Topaz and colleagues [2], LMA aneurysms were found in 22 patients, and they were associated with atherosclerotic coronary disease in all these cases. According to Lenihan and co-workers [3], the CAAs of patients less than 33 years of age are congenital, and these patients have otherwise normal coronary arteries. In most patients older than 33 years and in all patients older than 56 years, the CAA is caused by atherosclerosis [3]. Ebert and associates [4] reported the first case of CAA treated surgically; a CAA of the left circumflex artery was resected and reconstructed with an interposition vein graft. Usually, a different strategy has been adopted, where the CAA has been left as such, resected partially or isolated, and a simultaneous bypass with internal mammary artery or vein grafts has been performed [3,5–7]. In addition to bypass grafting, CAAs can be isolated to prevent thromboembolic complications, which are the main indication for operation. Most authors are of the opinion that the dilated segment can only be considered aneurysmatic after its diameter is triple the diameter of the artery of its origin [8].
We report a case of a congenital CAA of the left main stem resected and reconstructed successfully with an interposition arterial graft (anatomic correction) and an event-free follow-up for 5 years.
In May 1990, our patient suffered acute myocardial infarction unexpectedly at the age of 27 years. She had no family history of cardiac disease, her serum cholesterol level was normal, she did not smoke, and her blood pressure was normal.
After heavy stress while jogging, she experienced severe deep chest pain, and was admitted into the hospital. ST elevations and deep Q waves developed on the anterior electrocardiographic leads. The creatine kinase values exceeded 3,000 IU/L, creatine kinase MB fraction, 21.6%, at 6 hours after the thrombolysis. Transthoracic and transesophageal echocardiography revealed anteroapical hypokinesia consistent with myocardial infarction. She was anticoagulated, and administration of ß-blocking medication was commenced. A bicycle exercise test at 100 W caused no significant electrocardiographic changes or chest pain 2 weeks after the acute myocardial infarction, nor later after 2 months. In July, cardiac catheterization was performed, which showed an akinetic anterior left ventricular scar, an LMA aneurysm more than 2 cm in diameter (Figs 1, 2
), and otherwise completely normal coronary arteries. Later, after another pain episode, the LMA aneurysm could be well visualized by transesophageal echocardiography. Carotid and vertebral angiographic studies showed completely normal vessels.
Five months after the acute myocardial infarction, resection and reconstruction of the LMA aneurysm with interposition internal iliac artery graft (Fig 3) was performed successfully. During cardiopulmonary bypass, the aorta, the pulmonary trunk, and the LMA with its branches were mobilized. Unimpeded visibility of the whole LMA could be obtained without transecting the pulmonary trunk. The aortic cross-clamp time was 69 minutes and the cardiopulmonary bypass time was 141 minutes. Antegrade blood cardioplegia was used. An autogenous internal iliac (hypogastric) artery graft was harvested and trimmed to match the excised LMA (Fig 3). After resection of the LMA and the aneurysm, both the distal anastomosis to the LMA bifurcation and the proximal one to the original aortic left coronary ostium were sutured with 6-0 monofilament polypropylene. The postoperative recovery was uneventful.
View larger version (32K):
[in this window]
[in a new window]
|
Fig 3. . Resection and reconstruction of the left main coronary artery (LMA) aneurysm with a free interposition internal iliac (hypogastric) artery graft. (Cx = circumflex artery; LAD = left anterior descending coronary artery.)
|
|
In the histopathologic study of the specimen, the normal layers of the artery could not be clearly distinguished. The intima showed variable fibrosis and fibromuscular proliferation with focal calcium deposits. The inner wall was covered by endothelium, but there were occasional accumulations of macrophage-like cells.
Regular follow-up studies revealed no further electrocardiographic or echocardiographic changes. Eleven months after the operation a control coronary angiogram was obtained, which showed excellent patency and configuration of the LMA and coronary arteries (Fig 4). Now, 5 years after the operation, the objective status and clinical findings have continued to be stable. She still goes jogging daily, and has no evidence of exercise-induced ischemia.
View larger version (169K):
[in this window]
[in a new window]
|
Fig 4. . Control angiogram 11 months after the reconstruction of the left main coronary artery (arrows) showing normal anatomy.
|
|
|
Comment
|
|---|
Multiple CAAs in childhood and at adolescence are usually late complications of Kawasaki disease. Angiography and transesophageal echocardiography as well as magnetic resonance imaging [9] can be used for the diagnosis and follow-up of CAAs. Solitary CAAs before atherosclerotic changes can be found and, when there is no history of predisposing risk factors such as polyarteritis nodosa, neurofibromatosis, or syphilis, are considered congenital. The cause of our patient's disease was certainly not atherosclerotic, nor was there any history consistent with the aforementioned diseases or risk factors [3].
In atherosclerosis, the destruction of the media layer gradually leads to dilatation. The conservative treatment consists of attempts to prevent thromboembolic complications by anticoagulants or antiplatelet drugs. The reports on the natural course of atherosclerotic CAA are variable. In the follow-up, occlusion of the aneurysmatic nonstenotic coronary artery caused infarction in all 5 patients reported by Rath and colleagues [10]. In our case the operation was considered necessary to prevent further acute myocardial infarctions when the patient continued to have attacks of angina.
Because of the rarity of LMA aneurysms, no general agreement as to the treatment has been reached. Some of the LMA aneurysms were treated conservatively or surgically with bypass grafts without exclusion in the early cases, and later by isolating the CAA with ligatures or resecting the CAA and performing simultaneously the necessary bypass grafts [3, 5, 7, 8]. We have previously used internal iliac (hypogastric) artery grafts in renal artery reconstructions in young patients with encouraging long-term results (unpublished data). Similar results have been reported by others [11]. A great saphenous vein graft has been used as an interposition graft after resection in some single cases of CAAs [4].
It is noteworthy that after sufficient mobilization of the main pulmonary artery it is not necessary to divide it to achieve unimpeded visibility of the entire left main trunk, although it may have to be divided if difficulties are encountered. Retrograde cardioplegia can be conducted continuously, as it has the advantage of preventing distal embolization and is widely considered better for myocardial protection in complex and redo cases [6]. Antegrade cardioplegia, which was used in our case, turned out to be safe as well.
An arterial graft taken from a healthy internal iliac (hypogastric) artery seems to have ideal dimensions for the replacement of an LMA aneurysm. This method also seems to give a definitive and durable result. In the control angiogram obtained after 1 year, the patency of the internal iliac artery free graft was perfect and the diameter similar to that of a normal LMA, and the patient has remained event-free for 5 years as to her coronary disease. In patients with significant coronary disease, however, bypass grafts should be performed and the aneurysm itself should be isolated or resected to prevent later thromboembolism or rupture.
|
Footnotes
|
|---|
Address reprint requests to Dr Lepojärvi, Cardiothoracic Surgery, Division of Surgery, Oulu University Hospital, FIN -90220 Oulu, Finland.
|
References
|
|---|
- Swaye PS, Fischer LD, Litwin P. Aneurysmal coronary artery disease. Circulation 1983;67:134–8.[Abstract/Free Full Text]
- Topaz O, DiSciascio G, Cowley MJ, et al. Angiographic features of left main coronary artery aneurysms. Am J Cardiol 1991;67:1139–42.[Medline]
- Lenihan DJ, Zeman HS, Collins GJ. Left main coronary artery aneurysm in association with severe atherosclerosis: a case report and review of the literature. Cathet Cardiovasc Diagn 1991;23:28–31.[Medline]
- Ebert PA, Peter RH, Gynnells JC, Sabiston DC. Resecting and grafting of coronary artery aneurysm. Circulation 1971;43:593–698.[Abstract/Free Full Text]
- Hawkins JW, Vacek JL, Smith GS. Massive aneurysm of the left main coronary artery. Am Heart J 1990;119:1406–8.[Medline]
- LaMendola CL, Culliford AT, Harris LJ, Amendo MT. Multiple aneurysms of the coronary arteries in a patient with systemic aneurysmal disease. Ann Thorac Surg 1990;49:1009–10.[Abstract]
- Fukaya Y, Miyakawa M, Senga O, Hikita H, Kouzu S, Tunemoto H. Surgical management of the left main coronary artery aneurysm. Ann Thorac Surg 1994;57:228–30.[Abstract]
- Morshuis WJ, Noyez L, Skotnicki SH, Lacquet LK. Surgical treatment of an isolated coronary artery aneurysm: an alternative approach [Letter]. J Thorac Cardiovasc Surg 1991;101:369–71.
- Pucillo AL, Schechter AG, Moggio RA, Kay RH, Baum SJ, Herman MV. MR imaging in the definition of coronary artery anomalies. J Comput Assist Tomogr 1990;14:171–4.[Medline]
- Rath S, Har-Zahav Y, Battler A, et al. Fate of non-obstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report. Am Heart J 1985;109:785–91.[Medline]
- Van Bockel JH, van Schilfgaarde R, van Brummeln P, Terpstra JL. Long-term results of renal artery reconstruction with autogenous artery in patients with renovascular hypertension. Eur J Vasc Surg 1989;3:515–21.[Medline]
This article has been cited by other articles:
|
|
|
|
 
C. A. Anderson, F. Filsoufi, A. Kadner, and D. H. Adams
Repair of a left main coronary artery aneurysm using the circumflex femoral artery as a Y-interposition graft
Ann. Thorac. Surg.,
July 1, 2004;
78(1):
314 - 316.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Turkay, I. Golbasi, N. Sahin, M. Kabukcu, and O. Bayezid
Surgical management of an atherosclerotic aneurysm of the left main coronary artery
J. Thorac. Cardiovasc. Surg.,
September 1, 2001;
122(3):
626 - 627.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Eguchi, S. Kondoh, Y.-i. Takagi, K. Tsuchihashi, M. Abiru, Y. Minatoya, R. Seino, and Y. Fujise
Giant Noninflammatory and Nonatherosclerotic Coronary Arterial Aneurysm in the Left Main Trunk Assessed by Intravascular Ultrasound Imaging: A Case Report
Angiology,
July 1, 2000;
51(7):
599 - 602.
[Abstract]
[PDF]
|
|
|
Top
Abstract
Introduction
