Ann Thorac Surg 2002;73:1979-1981
© 2002 The Society of Thoracic Surgeons
Case report
Stenosed kinking of the left main coronary artery combined with an aneurysm of the ascending aorta
Paul P. Urbanski, MDa*,
Yvonne Lindemann, MDa,
Alexander Siebel, MDa
a Herz- und Gefäss-Klinik, Bad Neustadt, Germany
Accepted for publication November 1, 2001.
* Address reprint requests to Dr Urbanski, Herz- und Gefäss-Klinik, Salzburger Leite 1, Bad Neustadt 97616, Germany
e-mail: urbanski{at}kardiochirurg.de
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Abstract
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Stenosed kinking of the left main coronary artery is described in a 60-year-old man with an aneurysm of the ascending aorta and severe aortic valve insufficiency. An elective complete ascending aorta replacement using a valved composite graft was performed along with a shortening and direct implantation of the left main coronary artery. The right coronary artery was reimplanted as a Carrel-button.
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Introduction
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The combination of an ascending aorta aneurysm with a stenosed kinking of the elongated left main coronary artery is very rare. To our knowledge, no comparable case has been described. We report a simple and successful surgical treatment for this condition. The 60-year-old patient was admitted to surgery with severe aortic valve insufficiency and an ascending aorta aneurysm with a diameter of 6 cm diagnosed by echocardiogram and computed tomography. A coronary angiography showed a stenosed kinking of the elongated left main coronary artery 1 cm distal from the ostium (Fig 1).
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Fig 1. Preoperative coronary angiography shows a stenosed kinking of the elongated left main coronary artery.
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The patient suffered for 2 years from dyspnea, recently triggered by little effort (New York Heart Association class III). He did not complain of stenocardia. The electrocardiogram showed a sinus rhythm and there were no signs of ischemia or myocardial infarctation. The kinking of the left main coronary artery was therefore interpreted as coincidental.
We performed an elective complete ascending aorta replacement by composite graft using a 27-mm St. Jude Medical (SJM) Regent mechanical valve prosthesis (St. Jude Medical Inc, St. Paul, MN) and a collagen-coated woven graft (InterGard; InterVascular, La Ciotat, France). Both coronary ostia were excised from the aortic wall as Carrel buttons. The left main coronary artery had been displaced by the aneurysm, seemed to be elongated, and showed kinking at a 90° angle, 1 cm from the ostium (Fig 2A).
An incision was made from the ostium to the left main coronary artery. At the location of the kinking, the artery showed a flap of the intima and was dilated to a diameter of 4 mm. The left main coronary artery, shortened by 5 mm, received another 5-mm longitudinal incision (Fig 2B) and was implanted directly into the graft end-to-side in cobra-head fashion. The right coronary artery was implanted into the graft as a Carrel button.
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Fig 2. (A) Schematic view of the elongated left main coronary artery. Dashed lines show the level of shortening and the longitudinal incision into the artery. (B) The left main coronary artery is shortened and longitudinally incised.
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Myocardial protection was instituted with antegrade cold crystalloid cardioplegia. The duration of aortic cross-clamp time and extracorporal circulation was 98 and 128 minutes, respectively. The lowest rectal temperature was 28°C. Histologic examination of the resected aortic wall showed a complete loss of the elastic fibers in the tunica media.
Postoperative course was free from complications with the exception of a short episode of atrial fibrillation. A coronary angiography performed on the 11th postoperative day showed a normal left main coronary artery (Fig 3).
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Comment
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With a prevalence up to 1%, coronary anomalies are rarely seen [1] and even more rarely reach clinical relevance. However, from a surgeon’s point of view, it is important to know any possible anatomical anomalies or pathologic conditions of the coronary arteries before aortic root surgery. A coronary angiography of the ascending aortic aneurysm before elective surgery is useful even in younger patients because of a possible presence of asymptomatic coronary anomalies or other pathologic conditions. Cardiac computed tomography is a recent alternative to assess coronary status in selected cases.
In the case described, we were able to diagnose the stenosed kinking of the left main coronary artery. It seems to be related mainly to the elongation of the coronary artery due to its altered wall and not to the displacement of the ascending aorta by the aneurysm. To prevent later occurrence of relevant coronary stenosis due to elongation, we shortened the left main trunk before implantation to the aortic prosthesis in anatomical position.
We believe that the stretching of the coronary artery and the implantation into the Dacron graft in a nonanatomical location is insufficient and potentially hazardous. Stenosed kinking is characterized by a loss of elasticity and a subsequent fixation, and therefore can not be completely removed by stretching with the risk of a persisting stenosis. Determination of the correct nonanatomic implantation site for the coronary artery would also be very difficult because it has to be done before completing the distal anastomosis between the graft and the aorta. This could lead to unpredictable complications due to compression or high tension of the anastomosis and should therefore be avoided [2].
Complete replacement of the ascending aorta using a modified Bentall technique with resection of the aortic wall and direct implantation of coronary ostia is currently the preferred surgical procedure due to improved results and a lower incidence of pseudoaneurysms and consecutive reoperations [3–5]. The use of this technique is an added advantage and permits the surgical treatment of coronary anomalies or other pathologic conditions as in this unique case, kinking of the left main coronary artery.
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References
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Becker A.E. Coronary artery anomalies. In: Becker A.E., Anderson R.H., eds. Cardiac pathology. London: Gower Medical Publishing, 1983:246-248.
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Urbanski P.P. Aortic root replacement with coronary button reimplantation. Eur J Cardiothorac Surg 2000;18:732.[Free Full Text]
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Kouchoukos N.T., Warcing T.H., Murphy S.F., Persillo J.B. Sixteen year experience with aortic root replacement: results of 172 operations. Ann Thorax Surg 1991;214:308-320.
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Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Composite valve replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427-439.[Abstract/Free Full Text]
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Niederhäuser U., Rüdiger H., Künzli A., et al. Surgery for acute type A aortic dissection: comparison of techniques. Eur J Cardiothorac Surg 2000;18:307-312.[Abstract/Free Full Text]
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Abstract
Introduction
