Ann Thorac Surg 1998;65:561
© 1998 The Society of Thoracic Surgeons
Case Reports
Coronary Artery Aneurysm Repaired With Saphenous Vein Patch Plasty
Yukinori Moriyama, MD,
Kouichi Hisatomi, MD,
Shinji Shimokawa, MD,
Akira Taira, MD,
Shinichi Arima, MD
Second Department of Surgery, Kagoshima University, Faculty of Medicine, Kagoshima City, Japan
First Department of Internal Medicine, Kagoshima University, Faculty of Medicine, Kagoshima City, Japan
Accepted for publication September 23, 1997.
Dr Moriyama, Second Department of Surgery, Kagoshima University, Faculty of Medicine, Sakuragaoka 8-35-1, Kagoshima City 890, Japan.
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Abstract
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The presence of atherosclerotic coronary artery aneurysms is not always considered to be an operative indication. However, progressively expanded coronary artery aneurysms may have the potential for complications such as rupture or embolism. We present a case of successful repair of a coronary artery aneurysm located above the first septal perforator in the left anterior descending coronary artery using a saphenous vein patch and simultaneous construction of a right gastroepiploic artery graft to the occluded right coronary artery. Follow-up angiography at 6 months after operation revealed complete disappearance of the aneurysm with no luminal stenosis and a preserved large septal branch. The right gastroepiploic artery graft was also found to be widely patent.
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Introduction
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The presence of discrete, localized atherosclerotic coronary artery aneurysms (CAAs) is not always considered an operative indication [1] [2]. However, progressively expanded CAAs, even if they are true or false aneurysms, may have potential complications such as rupture or embolism, leading to a fatal outcome. We present here a patient who underwent successful repair of a CAA located in the proximal left anterior descending coronary artery using a saphenous vein patch and simultaneous construction of a right gastroepiploic artery graft to the occluded right coronary artery.
The patient was a 61-year-old man who initially presented in March 1991 with complaints of substernal chest pain. Coronary angiography showed a total occlusion of the proximal right coronary artery, a 75% stenosis of the left circumflex coronary artery, and a discrete CAA located above the first septal perforator in the proximal left anterior descending artery. The aneurysm measured 4.5 x 4.0 mm by comparison with the angiography catheter (Fig 1A). Percutaneous transluminal coronary angioplasty was performed for the left circumflex artery, which had a remnant stenosis of 25%. Subsequently the patient became asymptomatic. In October 1996, however, follow-up angiography revealed an enlarged CAA sized 15 x 15 mm in the left anterior descending artery (Fig 1B). Thallium 201 stress test showed posterior reversible ischemia.
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(A) Angiogram shows the small left anterior descending coronary artery aneurysm in 1991. (B) The aneurysm expanded remarkably and reached 15 x 15 mm in diameter in October 1996. (C, D) Follow-up right anterior oblique (C) and left anterior oblique (D) angiograms show no aneurysmal dilatation left in the coronary artery at 6 months after operation. The septal branch is widely patent. Arrows indicate aneurysm.
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The patient was referred to our institution for surgical management of CAA and occluded right coronary artery. At operation, the aneurysm was found to be bluish and was soft on palpation. The sacciform aneurysm was opened, and its thinned wall was excised and repaired with a saphenous vein patch sutured to the firm lateral arterial wall, while the orifice of the major septal branch was confirmed. There was no thrombus in the lumen. Then, the right gastroepiploic artery was anastomosed to the posterior descending branch of the right coronary artery.
The patient had an uneventful postoperative course. Histologic study of the specimen taken from the aneurysm wall revealed remarkable atherosclerotic change. Postoperative stress test showed no ischemia. Follow-up angiography 6 months after operation revealed complete disappearance of the aneurysm, with no luminal stenosis and a preserved large septal branch (Fig 1CFig 1D). The right gastroepiploic artery graft was also found to be widely patent.
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Comment
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According to the literature [1] [2] [3] [4] [5], the mere presence of an atherosclerotic CAA does not always warrant operative intervention. In the present case, however, the aneurysm enlarged progressively during a relatively short follow-up interval in association with the need for additional therapy for posterior reversible ischemia. The optimal treatment of CAA remains to be elucidated at this point; it may differ from patient to patient [3] [4] [5]. However, exclusion of left anterior descending artery aneurysms may be at high risk of inadvertent occlusion of important coronary branches, which may lead to hemodynamic instability as in the case reported by Cohen and colleagues [5]. Therefore, not to sacrifice these important septal branches we employed an alternative approach chosen especially for the true sacciform- type aneurysm: aneurysmectomy with saphenous vein patch plasty while confirming the orifice of the septal branch under direct vision. Our procedure can maintain antegrade flow, thus avoiding the need for any bypass grafting to the distal segment. Although the early result is promising, greater experience and longer follow-up are definitely needed to assess its value.
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References
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- Hartnell GG, Parnell BM, Pridie RB Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients. Br Heart J 1985;54:392-395.[Abstract/Free Full Text]
- Tunick PA, Slater J, Kronzon I, Glassman E Discrete atherosclerotic coronary artery aneurysms: a study of 20 patients. J Am Coll Cardiol 1990;15:279-282.[Abstract]
- Bal ET, Plokker T, van den Berg EMJ, et al. Predictability and prognosis of PTCA-induced coronary artery aneurysm. Cathet Cardiovasc Diagn 1991;22:85-88.[Medline]
- Dralle JG, Turner C, Hsu J, Replogle RL Coronary artery aneurysms after angioplasty and atherectomy. Ann Thorac Surg 1995;59:1030-1035.[Abstract/Free Full Text]
- Cohen AJ, Banks A, Cambier P, Edwards F Postatherectomy coronary artery aneurysm. Ann Thorac Surg 1992;54:1216-1218.[Abstract]
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Abstract
Introduction
