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Ann Thorac Surg 2000;70:1397-1398
© 2000 The Society of Thoracic Surgeons

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Case report

Interposition vein graft for giant coronary aneurysm repair

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Thomas, Department of Cardiology, Desk F15, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: thomasj{at}cesmtp.ccf.org

	Abstract

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Coronary aneurysms in adults are rare. Surgical treatment is often concomitant to treating obstructing coronary lesions. However, the ideal treatment strategy is poorly defined. We present a case of successful treatment of a large coronary artery aneurysm with a reverse saphenous interposition vein graft. This modality offers important benefits over other current surgical and percutaneous techniques and should be considered as an option for patients requiring treatment for coronary aneurysms.

	Introduction

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Coronary aneurysms are rare. In the United States they are encountered in 1.5% to 5% of patients undergoing elective coronary angiography and typically involve the right coronary artery [1]. Risks include spontaneous rupture [2] or thrombotic or embolic complications [3], and they complicate the evaluation of distal coronary anatomy during angiography. However, the natural history of coronary aneurysms is unknown. Typically, aneurysms are repaired during concomitant treatment of obstructive coronary lesions, and multiple surgical options have been described. We present a patient successfully treated with a reverse saphenous interposition vein graft.

A 73-year-old woman presented with complaints of worsening exertional chest pain and shortness of breath. Cardiac catheterization demonstrated a large proximal–mid right coronary artery aneurysm (Fig 1). Intraoperative findings confirmed the preoperative diagnosis (Fig 2). Marsupialization of the aneurysm revealed no intracavitary thrombus or significant branching vessels. A short segment of reversed saphenous vein was anastomosed to the proximal and distal openings of the aneurysm (Fig 3). Owing to the poorly defined preoperative distal anatomy by the dilutional effect of the large aneurysm, an additional vein graft off the aorta was placed to the distal right coronary artery. On postoperative day 2, repeat cardiac catheterization demonstrated widely patent grafts and moderate stenosis of the native coronary artery distal to the interposition graft (Fig 4).

View larger version (138K): [in this window] [in a new window]   Fig 1. Preoperative cardiac catheterization demonstrates a significant isolated right coronary artery (RCA) aneurysm.

View larger version (85K): [in this window] [in a new window]   Fig 2. Intraoperative transesophageal echocardiography illustrates the aneurysm with the proximal and distal portions of the right coronary artery (RCA). (Ao = aorta;LA = left atrium; RA = right atrium.)

View larger version (96K): [in this window] [in a new window]   Fig 3. Intraoperative view of aneurysm after marsupialization and placement of reversed saphenous interposition vein graft. Box illustrates a close-up view.

View larger version (111K): [in this window] [in a new window]   Fig 4. Postoperative angiography demonstrates a patent interposition graft with a branching vessel just distal to the anastomotic site.

	Comment

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Preservation of the normal coronary artery flow pattern with an interposition graft has several advantages over other techniques. Proximal or distal ligation risks causing myocardial ischemia. Postoperative angiography in our patient demonstrated a right ventricular branch distal to the repair that was not visualized preoperatively. Even with meticulous dissection, ligation may have disrupted flow to this and possibly similar vessels and caused myocardial injury. Bypass grafting distal to the aneurysm, in the absence of significant arterial stenosis and without ligation, does not prevent the risks of rupture or embolization. However, in the presence of poorly defined distal anatomy preoperatively, additional distal bypass is indicated.

End-to-end native artery anastomosis is not always possible, particularly for patients with large aneurysms. Dilatation of the heart in the near term after weaning from cardiopulmonary bypass or long-term secondary to underlying cardiac disease may promote catastrophic anastomotic failure, suture line tension, and aneurysmal recurrence.

Although percutaneous coil embolization or coated stent placement does not require an open-chest surgical procedure [5, 6], it risks arterial thrombosis, distal embolization, or compromised coronary flow. Transcatheter stents suffer from long-term patency concerns and predispose to premature graft stenosis, leading to repeat coronary interventions. These risks should severely limit these procedures to those patients who cannot undergo the operation.

In conclusion, the physiologic advantages of reestablishing normal anatomy with an interposition vein graft makes this technique a superior alternative to other therapies.

	Acknowledgments

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Supported in part by grant 93–13880 from the American Heart Association, Greenfield, TX, grant 1R01HL56688, National Heart, Lung, and Blood Institute, Bethesda, MD, and grant NCC9–60, National Aeronautics and Space Administration, Houston, TX.

	References

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1. Syed M., Lesch M. Coronary artery aneurysm. Prog Cardiovasc Dis 1997;40:77-84.[Medline]
2. Masahiko S., Hirotaka T., Shuji K. Sudden death due to rupture of a coronary aneurysm in a 26 year-old male. Circulation 1998;97:705-706.[Free Full Text]
3. Harandi S., Johnston S.B., Wood R.E., Roberts W.C. Operative therapy of coronary arterial aneurysm. Am J Cardiol 1999;83:1290-1293.[Medline]
4. Channon K.M., Wadsworth S., Bashir Y.D.M. Giant coronary artery aneurysm presenting as a mediastinal mass. Circulation 1998;82:1307-1308.
5. Wong S.C., Kent K.M., Mintz G.S., et al. Percutaneous transcatheter repair of a coronary aneurysm using a composite autologous cephalic vein-coated Palmaz-Schatz biliary stent. Am J Cardiol 1995;76:990-991.[Medline]
6. Peterson M.A., Monsein L.H., Dangas G., Mehran R., Leon M.B. Percutaneous transcatheter management of giant coronary aneurysms. Circulation 1999;100:E8-E11.

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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): Fouad Azoury Bruce W. Lytle James D. Thomas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Firstenberg, M. S. Articles by Thomas, J. D. Search for Related Content PubMed PubMed Citation Articles by Firstenberg, M. S. Articles by Thomas, J. D.