|Home | About | Journals | Submit | Contact Us | Français|
Coronary artery aneurysms are clinically relevant, because thromboembolism, rupture, and hemodynamic problems related to compression may occur. Surgical management is not standardized, and an individual approach toward each aneurysm is prudent. Giant coronary artery aneurysms (larger than 20 mm in diameter) originate in different ways and are extremely rare, and their surgical treatment is also not well defined.
Herein, we report the case of a 63-year-old man who had 2 aneurysms of the circumflex coronary artery and a 65-mm aneurysm of the right coronary artery. The diagnosis was established by use of transesophageal echocardiography, magnetic resonance imaging, and coronary angiography. An intraoperatively discovered smaller aneurysm of the right coronary artery was ligated. The giant thrombus-filled aneurysm of the right coronary artery was partially resected, because it compressed the right atrium and ventricle. A graft of the greater saphenous vein was constructed to the distal right coronary artery. The smaller, noncompressing aneurysms in the circumflex coronary artery were excluded by means of proximal and distal suture ligation, and bypass grafting was performed with use of skeletonized left internal mammary artery. The procedures were successful. We discuss the reasons behind our individual approach toward our patient's aneurysms.
Coronary artery aneurysms can portend thromboembolism, rupture, and compression-related hemodynamic problems. Giant coronary artery aneurysm is an extremely rare abnormality of varying origins but with life-threatening complications. Surgical approaches are not well defined. Here, we present the case of a 63-year-old man who had multiple coronary artery aneurysms (one of which was 65 mm in diameter) and discuss our surgical management.
In October 2007, a 63-year-old man was admitted to our hospital for evaluation of a cardiac tumor that had been detected upon transthoracic echocardiography. His medical history included chronic obstructive pulmonary disease, for which inhalant aerosol therapy had been prescribed. He had coronary artery disease, and he had experienced a myocardial infarction and undergone balloon dilation of the right coronary artery (RCA) in 2000. At the current presentation, the patient reported increased dyspnea upon exertion in recent weeks.
Transesophageal echocardiography confirmed an extraventricular, spherical, perfused mass. Contrast magnetic resonance imaging revealed a 65-mm mass adjacent to the right lateral atrioventricular groove, with compression of the right ventricular inflow tract (Fig. 1). The mass, which involved all parts of the vascular wall, was identified as an aneurysm of the RCA, with thrombotic material inside. This diagnosis was confirmed upon coronary angiography. Two cherry-sized aneurysms of the proximal circumflex coronary artery (Cx) were also seen. The patient was scheduled for surgery.
After the institution of normothermic cardiopulmonary bypass, the patient underwent median sternotomy, with ascending aortic and right atrial cannulation and the antegrade infusion of warm-blood cardioplegic solution. A small proximal aneurysm of the RCA was discovered and isolated via ligation. The giant, compressing aneurysm of the RCA was opened (Fig. 2), the thrombus was removed, and the aneurysmal sac was partially resected for histologic examination. The residual vascular wall was oversewn, and the inflow and outflow of the aneurysm were closed by means of suture ligation. Due to lack of inflow after the ligation of the smaller RCA aneurysm, a graft of the greater saphenous vein was established to the distal RCA. The smaller aneurysms of the Cx were not resected; instead, they were ligated proximally and distally. Thereafter, a bypass was performed to the Cx with use of skeletonized left internal mammary artery (Fig. 3).
The patient's postoperative course was complicated by gastrointestinal ischemia. Resolution required a right hemicolectomy, from which the patient recovered completely.
Surgical management of coronary artery aneurysms is not standardized. This is particularly true with giant aneurysms, because of their rarity. Coronary artery aneurysms that exceed the diameter of normal adjacent segments or the diameter of the patient's largest vessel by 1.5 times (defined as “coronary dilation”) can be found in up to 5% of patients who undergo coronary angiography.1 However, the giant form of aneurysm (diameter, >20 mm) is extremely rare. Our patient's giant aneurysm was 65 mm in diameter.
This abnormality originates in different ways. Atherosclerosis is the chief cause of coronary artery aneurysms in adults, followed by Kawasaki disease.1 Other underlying conditions include congenital coronary artery fistula, connective-tissue disease, and arteritis.
Our patient had a history of atherosclerotic coronary artery disease, and he had undergone percutaneous transluminal coronary angioplasty (PTCA) of the proximal RCA in 2000. There was no known aneurysm of either the RCA or the Cx at that time. It is not clear whether a PTCA trauma in 2000 triggered the development of the giant aneurysm, which appeared to be a true aneurysm rather than a pseudoaneurysm in that it involved all parts of the vascular wall. Furthermore, the patient developed multiple aneurysms (in his case, in the asclerotic Cx) without prior catheter intervention. Accordingly, more than atherosclerosis alone might have been the cause. However, postoperative clinical and laboratory screenings for connective-tissue and rheumatologic disorders, particularly those with vascular involvement, were negative. In addition, histologic examination of the resected aneurysmal wall revealed only atherosclerotic changes.
Coronary aneurysms can be asymptomatic. However, they can portend life-threatening complications, such as thrombosis with possible myocardial infarction,2 rupture that results in cardiac tamponade,3 or compression of the atria or ventricles with subsequent heart failure.4 Therefore, surgery should be considered, certainly in the case of a giant, symptomatic aneurysm5 as was present in our patient.
Various surgical techniques can be applied, such as isolating or resecting the aneurysm and reconstructing the coronary course—for instance, by using an interpositional graft or by maintaining distal coronary flow via concomitant coronary artery bypass grafting (CABG). We decided to open our patient's giant aneurysm and to perform thrombectomy, because the thrombus-filled giant aneurysm of the RCA was compressing the right ventricular inflow tract. The much smaller aneurysms of the Cx were left intact, and we opted to exclude them from the circulation. Rather than reconstruct the original coronary course via an interpositional graft within the giant aneurysm, we performed CABG in order to restore the coronary flow. This was because of the lack of inflow after we ligated the proximal smaller aneurysm of the RCA. Also, CABG was much easier technically than the alternative.
As in this presentation of multiple coronary artery aneurysms, prudent surgical management involves consideration of the size, location, and pathophysiologic impact of each aneurysm. Effective elimination of the potentially severe complications of coronary artery aneurysms can thereby be achieved.
The authors thank Mrs. Stephanie Kreutzer, Department of Scientific Graphics, Charité Hospital, Berlin, Germany, for the artwork of Figure 3.
Address for reprints: Sebastian Holinski, MD, Department of Cardiovascular Surgery, Charité Hospital, Medical University, Schumannstr. 20/21, 10117 Berlin, Germany. E-mail: email@example.com