Ann Thorac Surg 2008;85:1795-1796. doi:10.1016/j.athoracsur.2007.10.053
© 2008 The Society of Thoracic Surgeons
Case Reports
Resection of Giant Coronary Artery Aneurysms in a Takayasu's Arteritis Patient
Samer Kanaan, MD*,
Craig Baker, MD,
Vaughn Starnes, MD
Department of Cardiothoracic Surgery, University of Southern California, Los Angeles, California
Accepted for publication October 15, 2007.
* Address correspondence to Dr Kanaan, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033 (Email: skanaan{at}earthlink.net).
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Abstract
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Takayasu's arteritis is a chronic vasculitis of unknown cause. Coronary arteries are affected in approximately 10% of cases with aneurysm formation being extremely rare. Coronary aneurysms (not related to Takayasu's arteritis) have been surgically treated with aneurysm resection and coronary bypass. We describe the case of a young woman found to have giant coronary artery aneurysms. She underwent resection of the aneurysms and short segment saphenous vein bypass to the right and left coronary arteries. In reviewing the literature, this seems to be the first case of Takayasu's arteritis related to coronary artery aneurysm treated surgically with a good result.
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Introduction
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Takayasu's arteritis is a chronic vasculitis of unknown cause with a predilection for the aorta and its branches [1–3]. Inflammation of the involved vessels usually leads to stenosis, but may result in aneurysm formation. Coronary arteries are affected in approximately 10% of cases with aneurysm formation being extremely rare [1, 3, 4]. We describe a case of giant coronary aneurysms in a patient with Takayasu's arteritis who was successfully treated by operative resection. We believe that this is the largest coronary artery aneurysm in Takayasu's arteritis surgically treated.
A 44-year-old woman with known Takayasu's arteritis had a surveillance computed tomographic scan of her chest. The computed tomographic scan demonstrated a 6.0-cm right coronary artery aneurysm, a 2.2-cm left coronary artery aneurysm, and a dilated aortic root (Fig 1A). In the operating room, transesophageal echocardiogram demonstrated flow in the right coronary artery aneurysm (Fig 1B). The patient underwent resection of the aneurysms, short segment saphenous vein bypass to the right and left coronary arteries, and replacement of the aortic root with a stentless graft (Fig 2).
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Fig 1. (A) Computed tomographic scan demonstrating 6-cm right coronary artery (RCA) aneurysm. (B) Transesophageal echocardiogram demonstrating 6-cm RCA aneurysm.
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Fig 2. Intraoperative photograph demonstrating resection and bypass of 6-cm right coronary artery aneurysm.
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The pathology report indicated disruption of arterial wall elastin fibers and atherosclerosis, consistent with the patient's history of Takayasu's arteritis. The patient's postoperative course was unremarkable and she was discharged home in stable condition on postoperative day 5.
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Comment
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Coronary artery aneurysms in Takayasu's arteritis rarely occur [1, 3]. Suzuki and colleagues [1] describe finding 8 cases of coronary artery aneurysm in Takayasu's arteritis, and all of these cases were autopsy reports. Endo and colleagues [3] described coronary ectasia and aneurysm formation in 4 patients with the largest diameter at 25 mm. None of these patients were treated surgically. Matsubara and colleagues [4] described 7 cases of coronary artery aneurysms in Takayasu's arteritis, and similar to other reports these were pathologic examinations.
Matsubara and colleagues [4] described three types of coronary lesions in Takayasu's arteritis, with aneurysm formation being the least common. Aneurysm formation usually occurred in young or middle-aged female patients similar to our case.
Coronary artery aneurysms are of concern because they cause stasis of blood flow, thrombosis, and can become enlarged or rupture. This can lead to myocardial infarction, cardiac tamponade, and sudden death [1]. Coronary aneurysms (not related to Takayasu's arteritis) have been surgically treated with aneurysm resection or ligation and coronary bypass [1, 5].
This case is a young female patient found to have giant coronary artery aneurysms. In reviewing the literature, it seems to be the first case of Takayasu's arteritis related to coronary artery aneurysm treated surgically with a good result.
We chose to use saphenous vein grafts in our young patient. We were concerned that future involvement of the subclavian artery in Takayasu's arteritis would jeopardize an internal mammary artery graft if used. In their discussion, Endo and colleagues [3] supported the idea that use of the internal mammary artery for bypass surgery in Takayasu's arteritis patients is not recommended.
Finally, in coronary bypass for patients with Takayasu's arteritis, graft occlusion occurs mainly at the proximal anastomotic site secondary to aortic intimal thickening [3]. In our young patient, this certainly will be a future point of concern that will need close follow-up in her postoperative care.
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References
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- Suzuki H, Daida H, Tanaka M, et al. Giant aneurysm of the left main coronary artery in Takayasu aortitis Heart 1999;81:214-217.[Abstract/Free Full Text]
- Khalaf HH, Arafah MR, Refaat AA, Ibrahim MF. Coronary artery bypass grafting for Takayasu arteritis with severe coronary, carotid, subclavian, and renal artery involvement and subsequent pregnancy Interact Cardiovasc Thorac Surg 2006;5:153-155.[Abstract/Free Full Text]
- Endo M, Tomizawa Y, Nishida H, et al. Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis J Thorac Cardiovasc Surg 2003;125:570-577.[Abstract/Free Full Text]
- Matsubara O, Kuwata T, Nemoto T, Kasuga T, Numano F. Coronary artery lesions in Takayasu arteritis: pathological considerations Heart Vessels 1992;7:26-31.
- Ishikawa K, Maetani S. Long-term outcome for 120 Japanese patients with Takayasu's disease Circulation 1994;90:1855-1860.[Abstract/Free Full Text]
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Abstract
Introduction
