Ann Thorac Surg 2004;78:1833-1836
© 2004 The Society of Thoracic Surgeons
Case report
Giant Pseudoaneurysm From Vieussens' Arterial Ring
Mladen J. Kocica, MD*,a,
Mile R. Vranes, MD, PhDa,
Petar L. Djukic, MD, PhDa,
Aleksandar Dj. Mikic, MDa,
Milos M. Velinovic, MD, PhDa,
Marija Havelka, MD, PhDb,
Vladimir I. Kanjuh, MD, PhDb
a Clinic for Cardiac Surgery, Institute for Cardiovascular Diseases, UC Clinical Centre of SerbiaBelgrade, Yugoslavia
b Institute for Pathology, Medical Faculty, UC Belgrade, Serbia, Yugoslavia
Accepted for publication July 17, 2003.
* Address reprint requests to Dr Kocica, Clinic for Cardiac Surgery, Institute for Cardiovascular Diseases, UC Clinical Centre of Serbia, 8th Kosta Todorovic St, Belgrade, Serbia 11000, Yugoslavia.
kocica{at}sezampro.yu
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Abstract
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A giant coronary pseudoaneurysm of uncertain cause, arising from Vieussens' arterial ring, was preoperatively diagnosed in an oligosymptomatic female patient. Successful off-pump surgical excision without additional bypass grafting was performed. Difficulties in diagnostic algorithm, as well as possible cause and extremely rare localization were discussed.
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Introduction
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In 1706, Raymond de Vieussens (1641–1715), French anatomist, described the proximal collateral intercoronary connection between the conus branch of the right coronary artery and a proximal right ventricular branch (left conus branch) of the left anterior descending coronary artery. Today's eponym of this arterial circle, known as Vieussens' arterial ring (VAR), appeared in the literature in the first edition, in 1858, of Henry Gray's famous textbook of anatomy. Later on it was established that VAR is a remnant of the embryonic conotruncal circle, which gives rise to the coronary ostia and makes a connection with the other two epicardial coronary circles (atrioventricular and interampullary), giving rise to epicardial coronary arteries [1].
The conus branch of the right coronary artery is the first ventricular branch of the right coronary artery. It passes anteriorly (from the right) around the arterial conus and terminates in several branches. It has a separate origin from the right sinus of Valsalva in about 50% of the population (as the "third coronary artery").
The left conus branch is the first and the largest of several right ventricular branches, originating from the proximal left anterior descending coronary artery. It passes anteriorly (from the left) around the arterial conus. In 48% of the population it forms the VAR, with the conus branch of the right coronary artery.
The clinical importance of VAR is evident in cases of the proximal left anterior descending coronary artery or, less frequently, the right coronary artery occlusions, where it provides salutary collateral blood flow. The presence of VAR also could be relevant in some surgical procedures (ie, Tetralogy of Fallot repair), in which an incision line runs along the conus of the pulmonary artery (possible injuries and bleeding). Pathologic conditions, primarily involving VAR, are extremely rare.
A previously healthy 51-year-old female presented with chest discomfort and ventricular extrasystolic arrhythmia on exertion. Chest roentgenogram revealed calcified mass in the middle mediastinum (Fig 1A, B). Ehocardiographic examinations (TTE and transesophageal echocardiography) have indicated a cystic nature of the intrapericardial tumor. Subsequent noninvasive investigations (serological tests, computed tomography, and nuclear magnetic resonance) were directed upon further elucidation of the nature, origin, and extent of the mass (suspecting a benign cardiac tumor or cardiac echinococcosis), but any firm conclusion could not be made (Fig 1C). Finally, we had to perform cardiac catheterization with selective coronary angiography.
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Fig 1. (A) Posteroanterior chest roentgenogram. (B) Right lateral chest roentgenogram. (Arrows (A and B) "tumor"; (C) "tumor" with calcified walls.) (C) Chest computed tomographic contrast scan.
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The most interesting finding on the coronary angiogram was discrete, anterograde contrast filling of the "tumor" from both the left anterior descending coronary artery and the right coronary artery systems. This was first observed from the left conus branch, during the left anterior descending coronary artery contrast filling (Fig 2–2,–3). Catheter tip placing in the right coronary artery ostium revealed a clear, normal angiogram upon filling (Fig 2–4). With slight tip displacement, we could enter the separate, adjacent to the conus branch of the right coronary artery ostium. Contrast injection in the conus branch of the right coronary artery also revealed a discrete opacification of the "tumor" (Figs 2–6). Those findings have indicated the presence of VAR and confirmed its connection with "tumor-like," aneurysmal structure.
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Fig 2. Coronary angiogram: (1) native, pre-contrast phase, revealing calcified "tumor"; (2, 3) discrete contrast filling of the "tumor" from the left conus branch of the left anterior descending coronary artery; (4) "clear" right coronary artery angiogram; (5, 6) selective conus branch of the right coronary artery angiogram with discrete contrast filling of the "tumor" (the right coronary artery and conus branch of the right coronary artery with separate, adjacent ostia). (LAD = left anterior descending coronary artery; LAO = left anterior oblique projection; LCB = left conus branch; RAO = right anterior oblique projection; RCA = right coronary artery; RCB = conus branch of the right coronary artery.)
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We decided to make a surgical exploration though a median sternotomy, with ECC stand-by. Intraoperatively, a 4 x 5 x 4 cm, noninfiltrating, subepicardial mass, compressing the right ventricular outflow tract, was found and easily mobilized. Pertaining, underlying arterial inflow and outflow vessels could be easily exposed. After bolus injection of heparin sodium, they were temporarily clamped. Uneventful short-term hemodynamic and electrocardiographic monitoring during the occlusion test allowed us to totally excise the mass after ligation and transection of blood vessels. The patient was discharged after 1 week of uneventful postoperative course in good condition and stabile sinus rhythm.
Pathohistological examination, using Masson and Wangieson-elastica (x100) staining (Fig 3), revealed a well-organized, thrombosed, and partially calcified pseudoaneurysm (absence of the elastic laminae), without significant inflammatory cellular infiltration or signs of advanced atherosclerotic degeneration.
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Fig 3. Photomicrograph of the excised pseudoaneurysm (Wangieson-elastica, x100). (Notice the absence of the elastic lamina, indicating the discontinuity of the vessel wall.) (Ca = calcium deposits; ENDO = endothelial surface; EPI = epicardial surface; FCT = fibrocollagenous tissue; Thr = intramural thrombosis.)
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Comment
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Aneurysmal coronary disease is a very specific, rare, and potentially dangerous entity, with precise incidence, cause, pathogenesis, treatment, and evolution that have not been clearly established. During the past decade, the number of reports describing ante mortem diagnosis and treatment of patients with aneurysmal coronary disease is permanently increasing [2–7]. Angiographic incidence of aneurysmal coronary disease, according to the two largest angiographic series, ranges between 0.15% and 5.3% [2, 4]. The principal objection to these and many other reports is that they lack more precise and uniformly accepted morphologic criteria, which could help distinguish coronary ectasia from aneurysmal disease. Moreover, classification of aneurysms according to their size also needs a critical review. For example, there is a big difference between old (> 8 mm) and new standards (> 50 mm) for "giant" aneurysms [2–5]. Shape, number, distribution of coronary aneurysms, and eventual presence of fistulous channels, should also be a standard part of each report, because sometimes it may be helpful in elucidation of aneurysmal cause. Arteriosclerosis has been identified as a leading cause of aneurysmal coronary disease, although the number of possible causing factors is permanently increasing [2]. In regard to the treatment options, it could also be very important to estimate the status of the entire coronary network. Even the presence of pure aneurysmal coronary disease, without accompanying coronary obstructive disease, is not innocuous [3, 4, 6]. Although there are controversial opinions regarding the best treatment, the majority of advocates are for surgical intervention of all symptomatic patients. The modalities of surgical approaches are numerous and reported results are excellent [2–7].
Coronary pseudoaneurysms could be regarded as a special, separate entity. The underlying mechanism implies either coronary dissection or nonfatal ("covered") coronary rupture. The most common causing factors include: chest trauma, intracoronary procedural (angiography, percutaneous transluminal coronary angioplasty, DCA, stent placement) or cardiac surgical complications and spontaneous coronary dissections. This last cause listed has been frequently reported during the past few years [8]. The contraceptive drugs and multiple factors during and after labor, leading to spontaneous coronary dissection, could be of particular interest with our patient. Even meticulous anamnesis could not reveal any possible cause, except multiple labors, for development of coronary artery pseudoaneurysm. The histology of the excised mass did not help us determine a reasonable cause or explanation either (Fig 3). Additional difficulties in setting the clinical diagnosis came from the well known fact that coronary (pseudo)aneurysms can mimic various cardiac and mediastinal tumors. Finally, the most peculiar finding was the localization of the pseudoaneurysm pertaining to VAR. We have performed an extensive literature review and could not find a single report of VAR pseudoaneurysm.
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References
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- Corone P, Corone A, Dor X, Binet JP. Coronary arteries and their variations: a n embryological explanation. C R Acad Sci III. 1984;299(11):451–458[Medline]
- Fraizer OH. Coronary artery aneurysms. Buxton B, Fraizer OH, Westaby S. Ischemic heart disease sugical management. London: Mosby International Ltd; 1999. p. 282–287
- Falsetti HL, Carroll RJ. Coronary artery aneurysm: a rewiew of literature with report of 11 new cases. Chest. 1976;69:630–636[Abstract/Free Full Text]
- Demopoulos VP, Olympios CD, Fakiolas CN, et al. The natural history of aneurysmal coronary artery disease. Heart. 1997;78:136–141[Abstract/Free Full Text]
- Said S, El Gamal M, van der Werf T. Congenital and atherosclerotic (acquired) coronary artery aneurysms. Coronary angiographic and morphologic observations in 10 patients. Int Angiol. 1998;7:206–210
- Harandi S, Johnston SB, Wood RE, Roberts WC. Operative therapy of coronary arterial aneurysm. Am J Cardiol. 1999;83:1290–1293[Medline]
- von Rotz F, Niederhauser U, Straumann E, Kurz D, Bertel O, Turina MI. Myocardial infarction caused by a large coronary artery aneurysm. Ann Thorac Surg. 2000;69:1568–1569[Abstract/Free Full Text]
- Celik SK, Sagcan A, Altintig A, Yuksel M, Akin M, Kultursay H. Primary spontaneous coronary artery dissections in atherosclerotic patients. Report of nine cases with review of the pertinent literature. Eur J Cardiothorac Surg. 2001;20:573–576[Abstract/Free Full Text]
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Abstract
Introduction
