Ann Thorac Surg 2004;78:314-316
© 2004 The Society of Thoracic Surgeons
Case report
Repair of a left main coronary artery aneurysm using the circumflex femoral artery as a Y-interposition graft
Curtis A. Anderson, MDa,
Farzan Filsoufi, MDb,
Alexander Kadner, MDa,
David H. Adams, MDb*
a Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
b Mount Sinai Medical Center, New York, New York, USA
Accepted for publication October 2, 2002.
* Address reprint requests to Dr Adams, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, New York, NY 10029, USA;
e-mail: david.adams{at}mountsinai.org
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Abstract
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Left main coronary artery aneurysms are rare, and treatment options are poorly defined. Here we report the surgical management of a female patient who presented with an acute coronary syndrome resulting from dissection of an aneurysmal left main. She was successfully managed with an interposition graft fashioned from the lateral femoral circumflex artery.
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Introduction
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Coronary artery aneurysms (CAA) are uncommon with an incidence ranging from 0.15 to 4.9% in cardiac catheterization series [1, 2]. Kawasaki's disease is the most common cause worldwide [3], but in the United States most aneurysms are thought to be a manifestation of atherosclerosis [1]. Most frequently, the proximal and midportions of the right coronary artery (RCA) are involved followed by the left anterior descending (LAD) and circumflex coronary arteries in approximately equal numbers [1]. Aneurysms of the left main coronary artery are rare, noted in only 0.1% of coronary angiograms [4]. Therapy is focused on the avoidance of thromboembolism with either surgery or anticoagulation. Because of the rarity of this condition, treatment strategies are not clearly defined. Here, we discuss a patient who presented with a dissecting left main coronary artery aneurysm extending to the proximal circumflex and LAD.
At the age of 32, this patient presented 3 days post-partum with an anterolateral myocardial infarction. Her past medical history was significant only for hypertension. Cardiac catheterization at this time revealed a 70% stenosis of the first diagonal, but was otherwise normal. She was medically managed and made an uneventful recovery. The etiology of the myocardial infarction was presumed to be hypercoagulability related to pregnancy. She had two subsequent pregnancies without complication.
Seven years later at the age of 39, she presented with unstable angina. She underwent a repeat angiogram, which revealed an aneurysm of the left main coronary artery, a 60% stenosis of the LAD and an occluded first diagonal branch (Fig 1a).
Her angina persisted despite anticoagulation and medical optimization and she was referred for surgical therapy.
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Fig 1. (a) Coronary angiogram (left anterior oblique view) demonstrating aneurysmal degeneration of the left main coronary artery extending to the proximal circumflex and left anterior descending artery. (b) Division of the pulmonary artery facilitates aneurysm exposure. Fresh thrombus is present within the false lumen of the aneurysm. (c) Lateral femoral circumflex artery with its natural bifurcation. (d) Completed anatomic reconstruction utilizing lateral femoral circumflex artery.
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After full sternotomy and heparinization, cardiopulmonary bypass was initiated between the ascending aorta and right atrium. She was cooled to 28°C, and intermittent antegrade and retrograde cold blood cardioplegia was administered for myocardial protection. We observed a 2.5 cm aneurysm extending throughout the length of the left main into the proximal circumflex and LAD. The pulmonary artery was divided 2 cm proximal to its bifurcation to optimize exposure. A longitudinal arteriotomy was made in the aneurysmal segment of the LAD revealing fresh thrombus (Fig 1b). Further inspection demonstrated that this thrombus was within a false lumen. The dissection extended throughout the length of the left main and into the mid-LAD. At this time, we decided to perform an anatomic reconstruction of the involved coronary arteries. A complete resection of the left main from the left coronary ostium to the proximal LAD and circumflex was performed. The left lateral circumflex femoral artery with its natural bifurcation was previously harvested and trimmed to match the resected segment (Fig 1c). The short branch of the Y-graft was anastomosed to the proximal circumflex artery in an end-to-end fashion with 7-0 polypropylene. The remaining distal branch was anastomosed to the proximal LAD, and first diagonal branch as a hood with a 7-0 polypropylene. Each of these anastomoses was performed taking care to include all layers of the vessel to prevent further dissection. The proximal anastomosis was performed in an end to side fashion to the original left coronary ostium using a running 6-0 polypropylene (Fig 1d).
All anastomoses were performed without tension and care was taken not to distort the Y-graft. Antegrade cardioplegia was delivered thru the aortic root to check for hemostasis of the anastomoses before closure of the pulmonary artery. Pulmonary artery continuity was restored using 4-0 polypropylene. As a precautionary measure, the left internal mammary (LIMA) was anastomosed to the apical LAD and a radial artery was anastomosed to the obtuse marginal. The patient was weaned easily from cardiopulmonary bypass and her postoperative course was uneventful.
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Comment
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Because of the rarity of CAA, treatment strategies and risks are not clearly defined. Complications can include thrombosis, embolization, dissection, and in rare cases rupture [1, 3]. The coronary artery surgery study (CASS) comprises the largest group of patients with CAA yet to be analyzed. Of the 20,087 patients evaluated by coronary angiography, 978 (4.9%) were found to have aneurysmal coronary artery disease. More than 50% of the patients with CAA had suffered a myocardial infarction prior to angiography, and more than 80% were found to have concomitant atherosclerotic coronary artery disease [1]. Although antiplatelet and anticoagulant therapy have been suggested, many patients will require surgery because of either associated atherosclerosis or complications of aneurysmal disease.
Our patient presented with an acute coronary syndrome warranting surgical therapy. A variety of surgical strategies have been used in the past to treat CAA. The most common technique involves ligation of the aneurysm and distal bypass, which has been described for the treatment of left main coronary artery aneurysms [5]. In rare cases, aneurysmectomy followed by direct end-to-end anastomosis has been performed [6], however, this procedure can rarely be performed without undue tension. An alternative approach has been to replace the aneurysmal segment with an interposition graft. Lepojarvi et al [7] reported arterial reconstruction of an aneurysm of the left main coronary artery, involving the LAD and circumflex arteries using a y-graft harvested from the internal iliac artery. Their result was excellent at 4 years.
We also preferred to use an arterial interposition graft in this young patient. In contrast to the approach of Lepojarvi et al, we decided to use the lateral femoral circumflex artery. This conduit was selected because of its size, natural bifurcation and ease of procurement relative to an internal iliac dissection. We added LIMA and radial artery grafts due to the extent of proximal dissection, as well as a safeguard to early spasm in our arterial interposition graft. The patient has done well without symptoms after 24 months of follow-up. We believe that the lateral femoral circumflex artery serves as an excellent arterial interposition graft for aneurysms of the left main coronary artery involving the proximal circumflex and LAD.
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References
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- Swaye P.S., Fisher L.D., Litwin P., et al. Aneurysmal coronary artery disease. Circulation 1983;67:134-138.[Abstract/Free Full Text]
- Hawkins J.W., Vacek J.L., Smith G.S. Massive aneurysm of the left main coronary artery. Am Heart J 1990;119:1406-1408.[Medline]
- Robinson F.C. Aneurysms of the coronary arteries. Am Heart J 1985;109:129-135.[Medline]
- Barettella M.B., Bott-Silverman C. Coronary artery aneurysms: an unusual case report and a review of the literature. Cathet Cardiovasc Diagn 1993;29:57-61.[Medline]
- Turkay C., Golbasi I., Sahin N., Kabukcu M., Bayezid O. Surgical management of an atherosclerotic aneurysm of the left main coronary artery. J Thorac Cardiovasc Surg 2001;122:626-627.[Free Full Text]
- Westaby S., Vaccari G., Katsumata T. Direct repair of giant right coronary aneurysm. Ann Thorac Surg 1999;68:1401-1403.[Abstract/Free Full Text]
- Lepojarvi M., Salmela E., Huikuri H., Karkola P. Repair of an aneurysm of the left main coronary artery. Ann Thorac Surg 1996;61:1247-1249.[Abstract/Free Full Text]
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Abstract
Introduction
