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Ann Thorac Surg 1999;68:1401-1403
© 1999 The Society of Thoracic Surgeons

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Case Reports

Direct repair of giant right coronary aneurysm

^a Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Oxford, England, United Kingdom

Address reprint requests to Dr Westaby, Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, England
e-mail: swestaby{at}ahf.org.uk

	Abstract

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We describe a novel method for surgical repair of giant right coronary aneurysm. Instead of aneurysm ligation and coronary bypass we mobilized the inflow and outflow and performed end-to-end anastomosis. This preserved the native vessel. Restudy in both patients confirmed the effectiveness of this technique.

	Introduction

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Apart from Kawasaki disease, coronary aneurysms are unusual and seldom reach a size where rupture is likely [1, 2]. Atheromatous disease usually affects all vessels producing ectasia, but rarely giant coronary aneurysms. We present 2 patients with giant right coronary aneurysms (> 10 cm) where surgical repair was undertaken. Instead of ligating the aneurysm with coronary bypass we restored direct continuity of the vessel by end-to-end anastomosis of the inflow and outflow.

	Case reports

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Patient 1
A 70-year-old man without previous cardiac symptoms presented with nonspecific chest pain. Plain chest roentgenogram showed a mass at the right pericardiophrenic angle. A computed tomographic scan showed this to be cystic with a diameter of 12 cm (Fig 1). A pericardial cyst was considered but in view of presenting symptoms coronary angiography was undertaken before needle aspiration. This showed a giant right coronary aneurysm 1.5 cm from the coronary ostium (Fig 2). There was general left coronary ectasia but no significant occlusive disease.

View larger version (100K): [in this window] [in a new window]   Fig 1. Computed tomographic scan showing a pericardial mass with a diameter of 12 cm.

View larger version (170K): [in this window] [in a new window]   Fig 2. Coronary angiogram showing a giant right coronary aneurysm 1.5 cm from the coronary ostium.

Transesophageal–echocardiography confirmed a large quantity of blood in the pericardium, but the aortic root and arch were normal and there was no aortic regurgitation. Instead, a circular 11-cm mass was defined anterior to the right atrium. Although a coronary aneurysm was considered, the enormous size and the absence of previous coronary symptoms cast doubt on the diagnosis. Urgent coronary and angiography was performed, which showed the left coronary tree to be normal. Two centimeters from the right coronary ostium, the contrast media filled a huge smooth-walled aneurysm with faint filling of the dominant distal right coronary, which appeared free from disease. The patient was taken directly to the operating room for surgical repair.

The operation was identical in each patient, irrespective of presentation. Median sternotomy was performed and the ascending aorta cannulated for arterial return. The right atrial appendage was located behind the aneurysm and a two-stage venous cannula inserted. Using normothermic cardiopulmonary bypass the aortic cross-clamp was applied and cold (4°C) St. Thomas’ cardioplegic solution delivered into the aortic root. The short proximal stem of the right coronary artery was occluded by finger pressure. After diastolic arrest the aneurysm was opened longitudinally and cardioplegia infused directly into the distal lumen of the right coronary artery. For the first patient a length of saphenous vein was harvested with the intention of ligating the inflow and outflow of the aneurysm and performing coronary bypass. However, the inflow and outflow could be easily approximated without tension, raising the possibility of direct end-to-end anastomosis using a circumferential rim of aneurysm wall. Accordingly the inflow and outflow were mobilized and anastomosed directly one to another with continuous 5-0 polypropylene. In each case a 2-mm probe was passed down the coronary into the posterior descending branch to exclude distal occlusive disease. On release of the aortic cross-clamp there was no anastomotic leak and cardiac activity resumed promptly. After de-airing the aortic root, cardiopulmonary bypass was discontinued with no ischemic changes on the electrocardiogram. Both patients recovered uneventfully and were restudied on the fifth postoperative day. In each patient the end-to-end anastomosis was barely recognizable (Fig 3).

View larger version (181K): [in this window] [in a new window]   Fig 3. Postoperative angiogram in patient 1. The arrow indicates anastomosis.

	Comment

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Our previous approach to repair of coronary aneurysms has been tailored to their site and size. Kawasaki aneurysms have been ligated and distal coronary flow achieved with a pedicled graft of left or right internal thoracic artery. Previously, we have performed direct repair of a posttraumatic aneurysm of the proximal left anterior descending coronary artery and preserved continuity of the native vessel [3]. In this patient we grafted the left internal thoracic artery to the distal left anterior descending coronary artery as a safeguard. However, in the patients described, both the proximal and distal right coronary were 4 mm in diameter and had a satisfactory runoff. Under these circumstances a bypass graft would have provided competitive flow.

Although simple and effective this technique should be reserved for those patients where the distal coronary artery has been seen to be without disease. The method is only useful when direct anastomosis can be performed without tension. Otherwise ligation of the artery and coronary bypass should be used, as is conventional.

The etiology of massive thin-walled right coronary aneurysm is presumably atheroma, although possibly congenital [1, 4]. In both patients histology of the aneurysm wall excluded the possibility of a false aneurysm. Both patients had atherosclerotic abdominal aortic aneurysms and were lifelong smokers with chronic obstructive airway disease. Both aneurysms were clearly chronic in nature because the right atrium was deformed.

Spontaneous rupture of a coronary aneurysm is unusual but given the size and consequent wall tension rupture was a likely event [1, 2, 5].

In summary, we presented 2 patients with giant right coronary aneurysms managed by direct repair. The etiology of a giant right coronary aneurysm is obscure but operation is advisable to prevent rupture [6].

	References

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1. Chapman R.W.G., Watkins J. Rupture of right coronary artery aneurysm into the right atrium. Br Heart J 1978;40:938-939.[Abstract/Free Full Text]
2. Wan S., LeClerc J.L., Vachiery J.L., Vincent J.L. Cardiac tamponade due to spontaneous rupture of right coronary artery aneurysm. Ann Thorac Surg 1996;62:575-576.[Abstract/Free Full Text]
3. Westaby S., Drossos G., Giannopoulus N. Posttraumatic coronary artery aneurysm. Ann Thorac Surg 1995;60:712-713.[Abstract/Free Full Text]
4. Wei J., Wang D.J. A giant congenital aneurysm of the right coronary artery. Ann Thorac Surg 1986;41:322-324.[Abstract]
5. Eid G.A., Lang-Lazdunski L., Hvass U., et al. Management of giant coronary artery aneurysm with fistulization into the right atrium. Ann Thorac Surg 1993;56:372-374.[Abstract]
6. Ebert P.A., Peter R.H., Gunnells C., Sabiston D. Resecting and grafting of coronary artery aneurysm. Circulation 1971;43:593-598.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stephen Westaby Giuseppe Vaccari Takahiro Katsumata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Westaby, S. Articles by Katsumata, T. Search for Related Content PubMed PubMed Citation Articles by Westaby, S. Articles by Katsumata, T.