Ann Thorac Surg 2008;85:2130-2132. doi:10.1016/j.athoracsur.2007.12.052
© 2008 The Society of Thoracic Surgeons
Case Reports
Giant Coronary Artery Aneurysm in the Left Main Coronary Artery: A Novel Surgical Procedure
Keiji Matsubayashi, MD, PhD*,
Tohru Asai, MD, PhD,
Osamu Nishimura, MD,
Takeshi Kinoshita, MD,
Hirohisa Ikegami, MD,
Atsushi Kambara, MD,
Tomoaki Suzuki, MD
Department of Cardiovascular Surgery, Shiga University of Medical Science, Tsukinowacho, Seta, Otsu, Shiga, Japan
Accepted for publication December 17, 2007.
* Address correspondence to Dr Matsubayashi, Shiga University of Medical Science, Second Department of Surgery, Tsukinowa, Seta, Otsu, Shiga, 520 2192, Japan (Email: mazbysh{at}aol.com).
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Abstract
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Giant coronary artery aneurysm is quite rare and the corresponding surgical strategy is difficult to standardize. We present the case of a patient with giant coronary aneurysm involving the left main coronary artery who underwent an aneurysmectomy and coronary artery reconstruction with direct suture of the coronary vessels. Because of compression of the main pulmonary artery, the left main coronary artery was reconstructed using interposition of a short artificial graft.
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Introduction
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Coronary artery aneurysm is an uncommon disease defined as coronary dilatation that exceeds the diameter of adjacent normal segments or the diameter of the patient's largest coronary vessel by 1.5 times, which is noted in 0.15% to 4.9% of patients undergoing coronary angiography [1]. On rare occasions, a coronary artery aneurysm grows progressively large enough to be called a giant coronary aneurysm [2]. Because of the rarity of giant coronary aneurysm, its treatment has not been standardized [3, 4]. We describe a unique surgical procedure for giant coronary aneurysm in the left main coronary artery (LM). The left anterior descending coronary artery (LAD) was reconstructed with interposition of a short segment of a woven polyester graft (InterVascular Inc, Montvale, NJ).
A 74-year-old woman with cardiac hypertrophy was feeling general malaise and consulted her family doctor. The patient had undergone echocardiography at the age of 69, which had revealed a large coronary aneurysm in the LM measuring about 5 cm at its largest diameter. There had been no subsequent medical follow-up. A computed tomographic scan of the chest showed that the coronary aneurysm had enlarged to 8 cm in diameter. A coronary angiogram and a coronary computed tomographic scan showed the coronary aneurysm to be located in the distal LM above the bifurcation of the LAD and the left circumflex (Cx); the left coronary branches were dilated and distorted (Fig 1). Using a median sternotomy, an aneurysmectomy and reconstruction of the coronary arteries were performed under cardiopulmonary bypass established through cannulation of the ascending aorta and the right atrium. The giant aneurysm measuring approximately 8 cm in diameter was located in relation to the anterior and superior surface of the heart (Fig 2A). After cross clamping of the ascending aorta, cold blood cardioplegia was delivered antegrade to arrest the heart. Retrograde cardioplegia was then administered every 20 to 30 minutes for myocardial protection. The aneurysmal wall was incised longitudinally; no thrombus was found. The lumina of the afferent LM and the efferent LAD and Cx were identified from inside the aneurysmal sac. The left coronary artery was dilated and distorted as shown in the coronary computed tomographic scan and displayed calcification in some parts of the arterial wall. After total exclusion of the aneurysmal wall from the left ventricle, the stumps of the afferent LM, efferent LAD, and Cx were trimmed, measuring 8 mm, 10 mm, and 7 mm in diameter, respectively. The coronary arteries were reconstructed by sewing the stump of the proximal Cx end-to-end to the stump of the distal LM with 5-0 polypropylene, and the stump of the proximal LAD directly to the anterior wall of the ascending aorta where a small hole was created through the front of the main pulmonary artery. Because cardiopulmonary bypass weaning was compromised by compression of the main pulmonary artery by the directly sutured LAD, revision of the aorto-LAD connection was performed under cardioplegic arrest and a short segment of woven Dacron graft (10 mm in diameter) was interposed between them (Fig 2B). Cardiopulmonary bypass was discontinued without difficulty. A postoperative coronary computed tomographic scan showed no residual coronary aneurysm and good flow in the reconstructed coronary arteries. Postoperatively, the patient made an uneventful recovery.
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Fig 1. Preoperative computed tomographic scan shows a giant coronary aneurysm involving (A) the left main coronary artery, (B) the dilated left anterior descending coronary artery from the aneurysm, and (C, D) the efferent left circumflex originating from the aneurysm.
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Fig 2. Giant coronary aneurysm (surrounded by arrowheads) and (A) the dilated and distorted left anterior descending coronary artery, which was (B) reconstructed by interposition of a short segment of woven polyester graft (InterVascular Inc, Montvale, NJ).
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Comment
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Coronary artery aneurysm has been diagnosed with increasing frequency since the advent of coronary angiography [1]. However, giant coronary artery aneurysm is rarely seen. Li and colleagues [3] reported the incidence of coronary artery aneurysm and giant coronary artery aneurysm in their cardiac surgical population to be approximately 0.04% and 0.02%, respectively. Small aneurysms that produce no symptoms may be treated with simple observation, whereas giant coronary artery aneurysms that produce significant symptoms should be considered for surgical operation. Surgical treatment is applied most often to avoid complications that include extension, thrombosis, rupture, and coronary embolization. No typical surgical procedure has been established for giant aneurysm. Various surgical strategies have been adopted, such as resection, reconstruction, and isolation with coronary bypass [3, 4]. In cases with coronary artery fistula, closure of the fistula should be carried out if particularly symptomatic [5]. A recent report presented a case similar to ours in which a giant coronary artery aneurysm was excluded by ligation of the afferent and efferent vessels of the aneurysm with coronary artery bypass grafting [4]. In the present case, the aneurysm was located at the distal LM, just above the bifurcation of the LAD and Cx, both of which became dilated and elongated. Accordingly, during the operation, both the efferent LAD and Cx were completely isolated and reconstructed by direct anastomosis to the ascending aorta and the afferent stump of the LM without coronary artery bypass grafting. Because the anti-anatomical reconstruction of the proximal LAD compressed the main pulmonary artery and thus compromised cardiopulmonary bypass weaning, we decided to revise the aorto-LAD connection under cardioplegic arrest and reconstructed the LAD with interposition of a short segment of woven Dacron graft to relieve the main pulmonary artery compression. Autogenous saphenous vein graft was unavailable because of the considerably dilated LAD. Therefore, we had to choose an artificial graft of an adequate size with a 10-mm diameter to connect with the ascending aorta and the efferent LAD. There are no previous reports of the use of an artificial graft for the reconstruction of the coronary artery after dissection of a giant coronary aneurysm. However, the only problem involved is the risk of coronary thrombosis or embolization due to the artificial graft. The patient was given aspirin and Coumadin (warfarin; Eizai Inc, Tokyo, Japan) as a preventative measure. This novel procedure was devised in view of the specific needs of the present case. The patency of the artificial coronary graft was successfully confirmed by follow-up coronary computed tomography and angiography.
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References
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- Syed M, Lesch M. Coronary artery aneurysm: a review Prog Cardiovasc Dis 1997;40:77-84.[Medline]
- Vranckx P, Pirot L, Benit E. Giant left main coronary artery aneurysm in association with severe atherosclerotic coronary disease Cathet Cardiovasc Diagn 1997;42:54-57.[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]
- Agarwal R, Jeevanandam V, Jolly N. Surgical treatment of a giant coronary artery aneurysm: a modified approach Ann Thorac Surg 2007;84:1392-1394.[Abstract/Free Full Text]
- Gandy KL, Rebeiz AG, Wang A, Jaggers JJ. Left main coronary artery-to-pulmonary artery fistula with severe aneurysmal dilatation Ann Thorac Surg 2004;77:1081-1083.[Abstract/Free Full Text]
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Abstract
Introduction
