Ann Thorac Surg 2007;84:1392-1394
© 2007 The Society of Thoracic Surgeons
Case Reports
Surgical Treatment of a Giant Coronary Artery Aneurysm: A Modified Approach
Richa Agarwal, MDa,
Valluvan Jeevanandam, MDb,
Neeraj Jolly, MDa,*
a Section of Cardiology, The University of Chicago, Chicago, Illinois
b Section of Cardiothoracic Surgery, The University of Chicago, Chicago, Illinois
Accepted for publication May 29, 2007.
* Address correspondence to Dr Jolly, University of Chicago Hospitals, 5841 S Maryland Ave MC 5076, Chicago, IL 60637 (Email: njolly{at}medicine.bsd.uchicago.edu).
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Abstract
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A common surgery for giant coronary artery aneurysms includes aneurysmal ligation and coronary artery bypass grafting. We report a patient with such an aneurysm involving the left main trunk in whom the aneurysmal characteristics precluded this approach. Surgical strategy was modified and the aneurysmal sac was dissected open to define the coronary vasculature before ligating the aneurysm and completing the bypass operation.
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Introduction
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Coronary artery aneurysms are uncommon and are mainly due to congenital malformation, atherosclerosis, Kawasaki disease, and vasculitic injury. Surgical treatment is offered when they are accompanied by significant obstructive disease or when these are large enough to promote coronary thrombosis and its attendant complications. There is no consensus on the preferred surgical approach, although ligation of the aneurysm is performed during most procedures. We report a case in which ligating the giant coronary artery aneurysm was technically not feasible, and an alternative strategy was used along with coronary artery bypass grafting.
A 43-year-old woman sought medical consultation for breathlessness and throbbing pulsations in her chest. These symptoms had begun 7 years earlier and had prompted her to seek a medical opinion on a few occasions since then. A chest roentgenogram was done after a consultation revealed a calcified mass adjoining the left cardiac border (Fig 1). A follow-up computed tomographic scan of the chest reported this calcified, vascular mass was suspicious for a myocardial tumor, possibly a sarcoma. The patient refused further work-up at that time, and was subsequently lost to follow-up. A worsening throbbing sensation in her chest, as well as worsening fatigue and reduced exercise tolerance, ultimately brought her back to seek medical attention. Cardiovascular examination was significant for visible cardiac pulsations in the upper left parasternal area, and a grade III/VI systolic murmur, heard best at the left third intercostal space. The remainder of the physical examination and a resting electrocardiogram were normal.
An echocardiogram revealed mildly decreased left ventricular function and the presence of a calcified mass impinging on the left main pulmonary artery. A magnetic resonance angiogram showed the calcified mass to be continuous with the left coronary artery, raising the suspicion of a coronary artery aneurysm. Coronary angiography revealed a large fusiform aneurysm of the left coronary artery involving the distal left main stem and the proximal segments of the left anterior descending artery and the left circumflex artery (Fig 2). The outer edge of the aneurysm identified by its calcified rim measured 4.5 cm in diameter. The lumen of the aneurysm measured 2.1 cm in diameter, suggesting a large thrombus burden layering the aneurysm. The remaining segments of the left coronary artery and the right coronary artery were free from any significant disease. Left ventricular systolic dysfunction was deemed secondary to myocardial infarctions from distal thromboemboli from within the aneurysm. The patient was referred for surgical management of her giant coronary aneurysm.
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Fig 2. Left coronary arteriogram showing the fusiform aneurysm involving the left main trunk and the proximal segments of the left anterior descending and left circumflex arteries. (LM = left main trunk; LAD = left anterior descending coronary artery; LCX = left circumflex artery.)
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Surgical exposure by a median sternotomy revealed a hard, calcified mass measuring approximately 5 cm in diameter in relation to the anterior and superior surface of the heart. There were dense pericardial adhesions that required careful dissection. The epicardial vessels were distorted by the large aneurysm, making their localization difficult (Fig 3). The patient was placed on cardiopulmonary bypass, and it was decided to expose the lumen of the aneurysmal sac to better define the coronary anatomy. Cold 4 to 1 ratio of blood cardioplegia was delivered antegrade to arrest the heart. Retrograde cardioplegia was then administered every 20 minutes for myocardial protection. The wall of the aneurysm was incised longitudinally, and a large thrombus burden was evacuated. The lumina of the afferent left main trunk and the efferent left anterior descending coronary artery and circumflex branches were identified from within the aneurysmal sac; probes were advanced into these vessels to confirm their identification from an epicardial inspection (Fig 4). Total exclusion of the aneurysmal mass was achieved by ligation of the afferent and efferent vessels of the aneurysm, including the left main coronary artery, the left anterior descending coronary artery, and the obtuse marginal and posterolateral branches of the left circumflex artery. The left internal mammary artery graft was sewn end to side to the mid-left anterior descending coronary artery. A saphenous vein graft was sewn end-to-side to the left posterolateral artery with a sequential anastomosis to the obtuse marginal artery. The entry point was closed from within the aneurysm. The patient’s postoperative course was uneventful.
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Fig 4. Luminal view of the dissected open aneurysm after extraction of the organized thrombus. Probes introduced into the lumina of the vessels distal to the aneurysm to identify target vessels.
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A repeat coronary angiogram was electively performed 6 months after surgery. All bypass grafts were patent and there was no opacification of the aneurysm antegradely from the left main trunk, which was ligated, or retrogradely from the bypassed left coronary branches. The portion of the left coronary artery involved in aneurysm formation had been successfully excluded from the coronary circulation. The patient continues to be asymptomatic on follow-up 2 years later.
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Comment
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Unrecognized coronary aneurysms have a high likelihood of progression to obstructive coronary artery disease, resulting in myocardial ischemia, infarction, or sudden death, with the highest mortality occurring in those with giant aneurysms [1]. The rarity of giant coronary aneurysms makes it difficult to standardize treatment or firmly establish guidelines supporting medical versus surgical management.
In our patient, revascularization was recommended because of the precarious location of the aneurysm, her worsening symptoms from left ventricular dysfunction, and the poor prognosis of unrevascularized giant coronary arteries. Although there have been recent reports of successful percutaneous interventions and stent placement for giant aneurysms [2], the anatomy and the extent of the calcified aneurysm in our patient made a percutaneous approach unsuitable. There is no clear consensus to date as to which surgical approach is most appropriate; accordingly, a variety of surgical options, including thrombectomy, coronary artery reconstruction, and coronary artery bypass grafting, with or without aneurysm ligation, are used [3]. Case reports that examine these different operative strategies, alone or in association with each other, have shown the outcomes to be uniformly good [3, 4].
In our case the aneurysm involved the left main coronary artery, an uncommon site for coronary aneurysms, and essentially distorted the surface anatomy of the remaining left coronary artery (LCA). The identification of the distal targets for bypass grafting was not possible. The giant aneurysm was dissected open, the organized thrombus was extricated, and probes were inserted into the aneurysmal ends of the coronary lumina to identify the distal branches of the left coronary artery to facilitate optimal bypass grafting prior to plication of the aneurysm. Excluding the aneurysm from the native circulation was important to prevent further complications of left main coronary artery thrombosis, rupture, or embolization [4, 5]. Also it was critical to bypass all distal vessels independently communicating with the aneurysm, because the left main coronary artery had to be ligated to completely exclude the aneurysm from the coronary circulation. This modification to the standard surgical methodology was devised in view of the specific needs of our case and its success was confirmed by the follow-up angiogram.
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References
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- Onouchi Z, Hamaoka K, Kamiya Y, et al. Transformation of coronary artery aneurysm to obstructive lesion and the role of collateral vessels in myocardial perfusion in patients with Kawasaki Disease J Am Coll Cardiol 1993;21:158-162.[Abstract]
- Orlic D, Vitrella G, Corvaja N, Colombo A. New technique to seal a long giant coronary aneurysm with PTFE covered stents: a case report Catheter Cardiovasc Interv 2006;67:41-45.[Medline]
- Harandi S, Johnston SB, Wood RE, Roberts WC. Operative therapy of coronary arterial aneurysm Am J Cardiol 1999;83:1290-1293.[Medline]
- Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm J Thorac Cardiovasc Surg 2005;130:817-821.[Abstract/Free Full Text]
- 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]
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Abstract
Introduction
