Extensive aortic disease, such as atherosclerosis with aneurysms or dissections that involve the ascending aorta, can complicate the choice of a cannulation site for cardiopulmonary bypass.
To date, the standard peripheral arterial cannulation site has been the common femoral artery; however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable because of severe iliofemoral disease.
Arterial perfusion through the axillary artery provides sufficient antegrade aortic flow, is more likely to perfuse the true lumen in the event of dissection, and is associated with fewer atheroembolic complications.
From September 2000 through March 2004, 27 patients underwent right axillary artery cannulation for acute ascending aortic dissection (n = 16), ascending aortic aneurysm (n = 9), or coronary artery bypass grafting (n = 2). Direct artery cannulation was performed in the first 4 patients, and the last 23 patients were cannulated through a longitudinal arteriotomy via an 8-mm woven Dacron graft. Seventeen patients underwent hypothermic circulatory arrest and antegrade cerebral perfusion.
Two patients died intraoperatively: one due to low cardiac output and one due to diffuse bleeding. One patient suffered mild right-arm paresthesia postoperatively, but recovered completely. Axillary artery cannulation was successful in all patients; it provided sufficient arterial flow, and there were no intraoperative problems with perfusion.
In the presence of extensive aortic or iliofemoral disease, arterial perfusion through the axillary artery is a safe and effective means of providing sufficient arterial inflow during cardiopulmonary bypass. In this regard, it is an excellent alternative to standard femoral artery cannulation.
Aneurysm, dissecting/complications; aortic aneurysm/complications; arteriosclerosis/complications; axillary artery; cardiopulmonary bypass/methods; catheterization, peripheral/methods; extracorporeal circulation; femoral artery; reperfusion/methods; vascular surgical procedures
A case of false aneurysm originating from the ascending aortic cannulation site in the absence of mediastinal infection is described. Surgical treatment was carried out by means of limited cardiopulmonary bypass and hypothermic circulatory arrest, but the patient died early in the postoperative period. The technical failures responsible for the unsuccessful outcome are emphasized.
We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.
During the last 5 years, postoperative Pseudomonas mediastinitis has occurred in 2 of the 3,072 patients in our institution who have undergone cardiopulmonary bypass cardiac operations via a sternotomy. To our knowledge, there is no prior report in the English-language literature of postoperative Pseudomonas mediastinitis that originated at the aortic cannulation site, yet that was the site of origin in both of these patients.
The 1st patient developed a mycotic pseudoaneurysm of the ascending aorta at the cannulation site, secondary to the development of Pseudomonas mediastinitis following aortic valve replacement. This sequela was successfully treated by means of aneurysmectomy and closure of the aorta with a bovine pericardial patch, under cardiopulmonary bypass with circulatory arrest. The 2nd patient developed pseudoaneurysm and perforation of the aorta at the cardioplegia needle site, secondary to Pseudomonas mediastinitis following aortic and mitral valve replacement. This patient died. In both patients, the cannulation site and the cardioplegia needle site had been closed with pledgeted sutures. Pseudomonas aeruginosa was cultured from both sites.
Once the diagnosis of Pseudomonas mediastinitis is made following heart surgery, the patient should undergo reoperation, if possible, for removal of the foreign bodies (pledgeted sutures). In addition, these patients should be monitored with chest magnetic resonance angiography every 3 months for 1 year, in order to diagnose early development of a mycotic pseudoaneurysm and subsequent complications. (Tex Heart Inst J 2003;30:322–4)
Aneurysm, false; mediastinitis/prevention & control; Pseudomonas aeruginosa; pseudomonas infections; surgical wound infection/pathology
A saccular aortic arch aneurysm that is secondary to aortic arch coarctation and that is accompanied by a ventricular septal defect is a rare combination in the adolescent patient. Total simultaneous repair of all of these conditions is desirable, because of the higher morbidity and mortality rates of staged procedures—particularly when resection of the saccular aneurysm is delayed.
Herein, we discuss the case of a 16-year-old boy who underwent simultaneous surgical correction of these malformations. With the aid of cardiopulmonary bypass on the beating heart, the coarctation and the aneurysmal segment were resected, and a tubular Dacron graft was interposed. The ascending aorta and femoral artery were both then cannulated to ensure whole-body perfusion during cardiopulmonary bypass. The ventricular septal defect was closed with the patient under cardioplegic arrest. After 10 days, he was discharged from the hospital without sequelae. We conclude that single-staged repair of cardiac abnormalities and of an aortic arch aneurysm that is secondary to coarctation of the aortic arch can be performed safely and effectively in adolescent and adult patients by use of our technique.
Aorta/surgery; aortic aneurysm/physiopathology/surgery/ultrasonography; aortic coarctation/complications/physiopathology/surgery/ultrasonography; coronary disease/surgery; magnetic resonance angiography; methods; time factors
The Seldinger technique is a method of femoral cannulation that has been used to establish cardiopulmonary bypass. Reports of cannulation of the ascending aorta for antegrade perfusion using the Seldinger method are anecdotal. To the best of our knowledge, the approach described herein for direct cannulation of the ascending aorta with use of the Seldinger technique for antegrade perfusion has not been previously described in the English-language medical literature. This method is helpful when the surgeon is treating a patient who has a calcified ascending aorta, complicated aortic dissection, calcified femoral vessels, or a diseased thoracoabdominal aorta. In such cases, retrograde perfusion has been associated with severe complications as a result of atheromatous embolization from the descending thoracic aorta.
Herein, we describe our approach to cannulation for cardiopulmonary bypass, which entails insertion of an aortic cannula into the ascending aorta by means of the Seldinger technique. A soft-tip guidewire is inserted through an arterial entry catheter that has been used to puncture a hole in the wall of the vessel. Then the aortic cannula is introduced into the vessel, sliding along the guidewire. Guided by transesophageal echocardiography, the tip of the cannula is positioned carefully and is then advanced into the descending aorta. This positioning of the cannula decreases the chance of arterial embolization, thereby improving cerebral protection. If cannulation of the ascending aorta is not feasible, the transverse aortic arch or proximal descending aorta can be used.
Aorta, thoracic; cardiopulmonary bypass/adverse effects/methods; catheterization/methods; cerebral protection; intraoperative complications
The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options.
Three cases of lower aortic obstruction are described in which the diagnosis was made at operation.
Profound hypothermia with circulatory arrest was used for replacement of the mitral valve by a Starr Edwards prosthesis. Femoral perfusion was used and the diagnosis was made in the first case only because the rectal temperature fell precipitously during cooling, while the temperature in the upper part of the body was slow to fall. In this case disobliteration was not carried out, but in two further cases this was done through a bilateral femoral arteriotomy using Fogarty catheters.
All cases were seen during a period of 18 months among 35 mitral valve replacements.
Silent lower aortic obstruction may not therefore be a rare condition and might be responsible for hypotension during normothermic cardiopulmonary bypass when the femoral artery is used for cannulation. If the aortic root is used, the condition will not be discovered.
If exercise tolerance is greatly improved after successful operation symptoms of the obstruction may become manifest, and if further thrombosis occurs and symptoms are more acute they may be wrongly attributed to embolization from the valve replacement. Routine abdominal aortography during left heart studies should disclose a clinically silent obstruction.
Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection.
Femoral artery cannulation with retrograde perfusion is the most common method but because of the risk of malperfusion of vital organs and atheroembolism related to it different sites such as the axillary artery, the innominate artery and the aortic arch are used. Cannulation of these sites is not without risks of atheroembolism, neurovascular complications and can be time consuming. Another yet to be popularised option is the transapical aortic cannulation (TAC) described in this article. TAC consists of the insertion of the arterial cannula through the apex of the left ventricle and the aortic valve to lie in the sinus of Valsalva. Trans-oesophageal guidance is necessary to ensure correct placement of the cannula.
TAC is an excellent method of establishing cardiopulmonary bypass as it is quick, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of the true lumen.
In a series of 420 ascending aortic cannulations for cardiopulmonary bypass, major complications occurred in three patients. Aortic dissection occurred in one patient believed to be due to aortic cross-clamping. Avoidance of this manœuvre is suggested when the aorta is grossly atheromatous. Two patients developing false aneurysms due to mediastinal infection are described. Prevention of mediastinal infection and its treatment are discussed. The method of treatment of false aneurysms by deep hypothermia is described.
The current surgical treatment of dissecting thoracic aneurysms that originate above the aortic valve and dissect distally (Type I—De Bakey ) requires cardiopulmonary bypass for repair of the proximal intimal tear and obliteration of the false lumen [1, 2, 4, 5]. When the dissecting process extends toward the femoral arteries, cannulation of these vessels may result in perfusion of the false lumen. In addition, although a femoral cannula is inserted into the true lumen, perfusion of the false channel may occur through large reentry sites in the distal abdominal aorta or beyond the bifurcation. Retrograde arterial flow through the false lumen would jeopardize the blood flow to the central nervous system and to other vital organs. We have observed this complication in 2 patients with complete aortic dissection (Type I) during what appeared to be an otherwise adequate surgical procedure.
We report a clinical case of multiple mycotic aneurysms, in the ascending aorta, aortic arch, and descending aorta. The patient underwent surgery to replace the ascending aorta and aortic arch by means of a highly modified “elephant trunk” technique and with the aid of arterial cannulation from the right subclavian artery, which provided antegrade cerebral perfusion. Samples of purulent material taken from the aneurysmal wall yielded cultures positive for Staphylococcus aureus. The patient was treated with antibiotics for 6 weeks and then underwent a 2nd procedure for the aneurysmal resection of the descending thoracic aorta and the abdominal aorta, through a thoracic laparo-phrenicectomy. We comment on the clinical and surgical aspects of the case. (Tex Heart Inst J 2003;30:225–8)
Aneurysm, infected/surgery; staphylococcal infections/complications; Staphylococcus aureus
When there is an echocardiographic diagnosis of severe mobile atherosclerotic plaque in the aortic arch or descending aorta, perfusion toward the aortic arch during cardiopulmonary bypass may create a high risk of embolic neurologic injury. Other perfusion methods, such as cannulation of the femoral or axillary arteries, are not always possible, due to atherosclerosis. The ascending aorta may be an alternative site for perfusion, since it is less frequently diseased. We assessed a new technique of perfusion toward the aortic valve using a new cannula designed for this purpose (Dispersion aortic cannula).
Our study included 100 consecutive patients, 72 men and 28 women, with an average age of 68 ± 1.0 years (range, 39–89 years). There were no complications related to insertion of the cannula or perfusion. The ascending aorta could be cross-clamped and side-clamped without perfusion problems. Three deaths occurred; none was related to the cannulation technique. No intra-operative stroke occurred. Two patients suffered neurologic events, one on day 1 and the other on day 6; both had been fully alert after surgery. Perfusion toward the aortic valve appears to be safe and hemodynamically effective. This cannulation technique appears to be an acceptable alternative to present methods. Comparative studies will be needed to determine whether this alternative technique is effective in patients with severe aortic arch disease.
Aorta, thoracic/surgery; cardiac surgical procedures; cardiopulmonary bypass/methods; cerebrovascular accident/prevention and control; embolism, cholesterol/prevention and control; surgical instruments
We describe a technique for transapical cannulation in cases of acute aortic dissection. This method entails aortic cannulation via the apex of the left ventricle and the aortic valve. When this technique is used, retrograde perfusion prevents such fatal complications as malperfusion or cerebral embolism that can occur with femoral cannulation. Having found no disadvantage in this method, we recommend transapical cannulation as the best cannulation technique for acute aortic dissection.
Aneurysm, dissecting/surgery; aorta/surgery; cardiac surgical procedures/methods; perfusion/adverse effects/methods
Owing to the increased use of the axillary artery for arterial inflow during cardiopulmonary bypass, patients with previous cannulation at this site who require reoperation will be encountered more and more frequently. We describe the cases of 2 patients who required recannulation of the axillary artery for complex reoperations of the thoracic aorta. The technique and pitfalls are described.
The decision was made to reuse the previous cannulation site at the right axillary artery due to the presence of large pseudoaneurysms in proximity to the sternum. The old 8-mm Dacron stump was found and excised, and a new 8-mm Dacron graft was sutured to the right axillary artery for arterial inflow. In the 1st patient, the Dacron side-graft enabled insertion and subsequent inflation of an EndoClamp® within the Dacron graft of the ascending aorta, which obviated profound hypothermia. In the 2nd patient, recannulation of the right axillary artery enabled us to open the sternum at low flow using moderate hypothermia, given that antegrade cerebral perfusion was easily accessible in the event of a more prolonged arrest time. Both patients recovered fully, without neurovascular complications secondary to the recannulation of the right axillary.
Recannulation of the right axillary artery is safe during complex reoperation of the thoracic aorta. It avoids retrograde perfusion in the often-diseased descending thoracic aorta. Furthermore, sternal reentry may be performed under moderate hypothermia, because antegrade cerebral perfusion can be initiated with ease.
Aorta, thoracic/surgery; aortic aneurysm/surgery; axillary artery; cardiopulmonary bypass/methods; extracorporeal circulation/methods; vascular surgical procedures/methods
Mycotic aneurysms constitute a small proportion of aortic aneurysms. Endovascular repair of mycotic aneurysms has been applied with good short-term and midterm results. However, the uncommon aortoenteric fistula formation remains a potentially fatal complication when repairing such infective aneurysms. We present the case of an 80-year-old woman with thoracic and abdominal aortic mycotic aneurysms, which were successfully treated with endografting. However, the patient presented 3 months later with upper gastrointestinal bleeding secondary to erosion of the thoracic graft into the oesophagus. The patient was treated conservatively due to the high risk of surgical repair. There is currently little exposure to the management of mycotic aortic aneurysms. If suspected, imaging of the entire vasculature will aid initial diagnosis and highlight the extent of the disease process, allowing for efficient management. Aortic endografting for mycotic thoracic aneurysms is a high-risk procedure yet is still an appropriate intervention. Aortoenteric fistulae pose a rare but severe complication of aortic endografting in this setting.
The axillary artery is frequently used for cardiopulmonary bypass, especially in acute aortic dissection. We have cannulated the axillary artery using a side graft or by directly using Seldinger's technique. The purpose of this study was to assess the technical problems and complications of both cannulation techniques.
Materials and Methods
From January 2003 to December 2009, 53 patients underwent operations using the axillary artery for arterial cannulation. The axillary artery was cannulated with a side graft in 35 patients (side graft group) and directly using Seldinger's technique in 18 patients (direct group).
The results were compared between two groups, focusing on cannulation-related morbidities including neurologic morbidity. Arterial damage or dissection of the axillary artery occurred in 1 (2.9%) patient in the side graft group and in 1 (5.6%) patient in the direct group. Malperfusion and insufficient flow did not occur in either group. There were no postoperative complications related to axillary cannulation, such as brachial plexus injury, compartment syndrome, or local wound infection, in either group.
Technical problems and complications of the axillary arterial cannulation in both techniques were rare. Direct arterial cannulation using Seldinger's technique was done safely and more simply than the previous technique. It was concluded that both axillary arterial cannulation techniques are acceptable and it remains the surgeon's preference which technique should be used.
Aortic dissection; Axillary artery; Cannulation
Lesions of the ascending aorta associated with aortic valve disease are usually treated by implanting a prosthetic valved conduit (Bentall procedure). In this report, we present our experience in which a valved homograft conduit was used for the procedure.
Six patients underwent a Bentall procedure with the use of a cryopreserved valved homograft conduit. Two of the patients had annuloaortic ectasia, 2 had Marfan syndrome, and 1 had an atherosclerotic aneurysm of the aorta. One patient had severe aortic stenosis due to a bicuspid aortic valve, along with an aneurysm and localized dissection of the ascending aorta. In all of the patients, the aortic annulus was substantially dilated, with accompanying moderate-to-severe aortic regurgitation. A standard procedure was performed with moderate hypothermia, cardiopulmonary bypass, and aortic and bicaval cannulation. The ascending aorta and the aortic valve were replaced with a cryopreserved valved homograft conduit (aortic in 5 patients and pulmonary in 1). The native coronary ostia were anastomosed directly to the homograft.
Echocardiography, which was performed intraoperatively, before discharge from the hospital, and at follow-up visits (1 to 36 months), revealed good valve function without dilatation of the homograft conduits. There was 1 late death due to Aspergillus fumigatus endocarditis, 6 months postoperatively. In 1 patient, magnetic resonance imaging performed at 24 months revealed normal caliber of the homograft conduit.
We conclude that the Bentall procedure can be performed, safely and with excellent results, using cryopreserved homograft conduits.
Aneurysm, dissecting; aortic valve/abnormalities; aortic valve/surgery; aortic valve insufficiency/surgery; Bentall operation; blood vessel prosthesis; Marfan syndrome/surgery; transplantation, homologous
There are certain situations in redo cardiac surgery in adults where it may not be possible to use alternate arterial cannulation sites like the common femoral artery and axillary artery. We report a case where we established safe cardiopulmonary bypass with common carotid artery cannulation in an adult patient. The patient underwent aortic valve replacement for severe aortic regurgitation 8 months after repair of type A aortic dissection plus aortic valve resuspension.
Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue.
We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis.
Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication?
Selective antegrade perfusion via axillary artery cannulation along with circulatory arrest under deep hypothermia has became a recent trend for performing surgery on the ascending aorta and aortic arch and when direct aortic cannulation is not feasible. The authors of this study tried using moderate hypothermia with right brachial and femoral artery perfusion to complement the pitfalls of single axillary artery cannulation and deep hypothermia.
Materials and Methods
A retrospective analysis was performed on 36 patients who received ascending aorta or aortic arch replacement between July 2005 and May 2010. The adverse outcomes included operative mortality, permanent neurologic dysfunction and temporary neurologic dysfunction.
Of these 36 patients, 32 (88%) were treated as emergencies. The mean age of the patients was 61.9 years (ranging from 29 to 79 years) and there were 19 males and 17 females. The principal diagnoses for the operation were acute type A aortic dissection (31, 86%) and aneurysmal disease without aortic dissection (5, 14%). The performed operations were ascending aorta replacement (9, 25%), ascending aorta and hemiarch replacement (13, 36%), ascending aorta and total arch replacement (13, 36%) and total arch replacement only (1, 3%). The mean cardiopulmonary bypass time was 209.4±85.1 minutes, and the circulatory arrest with selective antegrade perfusion time was 36.1±24.2 minutes. The lowest core temperature was 24±2.1℃. There were five deaths within 30 post-op days (mortality: 13.8%). Two patients (5.5%) had minor neurologic dysfunction and six patients, including three patients who had preoperative cerebral infarction or unconsciousness, had major neurologic dysfunction (16.6%).
When direct aortic cannulation is not feasible for ascending aorta and aortic arch replacement, the right brachial and femoral artery can be used as arterial perfusion routes with the patient under moderate hypothermia. This technique resulted in acceptable outcomes.
Aorta, surgery; Cardiopulmonary bypass; Cerebral protection; Hypothermia
We report a case of ruptured mycotic aneurysm involving innominate artery requiring an urgent surgical treatment. A 62-yr-old woman presented with fever and dyspnea. Previously, she was diagnosed with colon cancer and received right hemicolectomy and one cycle of adjuvant chemotherapy. On echocardiogram, pericardial effusion was noted and emergency pericardiocentesis was performed. CT scan revealed aortic aneurysm involving ascending aorta and innominate artery, and thrombi surrounding those structures. Patch repair of the defect in the ascending aorta and ringed Goretex graft to bypass the innominate and ascending aorta were performed. We believe that this is the first case of ruptured mycotic aneurysm involving innominate artery.
Cannulation for cardiopulmonary bypass, although seemingly routine, can pose technical challenges. In patients undergoing repeat sternotomy, for example, peripherally established cardiopulmonary bypass may be necessary to ensure safe entry into the chest; however, establishing bypass in this way can sometimes be complicated by patients' body habitus. We describe a technique for direct cannulation of the infrahepatic abdominal vena cava that was required for emergent cardiopulmonary bypass. The patient was a 62-year-old woman who had presented with severely symptomatic left main coronary stenosis 3 months after elective aortic valve replacement. She had gone into cardiogenic shock as general anesthesia was being induced for repeat sternotomy and myocardial revascularization. Emergent establishment of femorofemoral cardiopulmonary bypass was precluded by difficulties in advancing the femoral venous cannula beyond the pelvic brim. Hence, an emergent celiotomy was performed, and the abdominal vena cava was directly cannulated to establish venous drainage for cardiopulmonary bypass. The rest of the operation was uneventful. Our technique for direct cannulation of the infrahepatic abdominal vena cava may be used in exceptional circumstances. Necessary precautions and potential pitfalls are also presented.
Cardiopulmonary bypass/instrumentation/methods; shock, cardiogenic; vena cava, inferior
Aneurysms of the left main coronary artery are rare with an incidence of 0.1% in large angiographic series. The majority are atherosclerotic in origin. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic and idiopathic. The primary complication is myocardial ischemia or infarction, with rupture being rare. Treatment options include anticoagulation, custom made covered stents, reconstruction, resection, and exclusion with bypass.
A 66 year-old man was referred for evaluation of a 2 × 2 centimeter saccular aneurysm originating from the distal left main coronary artery. There was associated calcification and mild stenosis of the LM. The workup was prompted by a non-ST elevation myocardial infarction suffered following a laparotomy for a ruptured appendix. The past medical history was pertinent for hypertension, hyperlipidemia, and a left carotid endarterectomy.
Cardiopulmonary bypass with hyperkalemic cardioplegic arrest was utilized. The aneurysm was exposed in the atrioventricular groove. The aneurysm was resected and oversewn. Calcification precluded patch angioplasty. The patient then underwent coronary bypass grafting with the left internal thoracic artery placed to the left anterior descending artery and a reversed greater saphenous vein graft to an obtuse marginal branch of the circumflex artery. The postoperative course was uneventful and discharge to home occurred on the fourth postoperative day. Surgical pathology confirmed an atheromatous coronary artery aneurysm.
Left main coronary artery aneurysms in adult patients are predominantly atherosclerotic in origin. The clinical presentation is that of myocardial ischemia, likely from associated embolism. Rupture is rare. Operative treatment is exclusion and revascularization.
A case of false aneurysm related to the left side of the heart with a connection to the right ventricular outflow tract was found by echocardiography after complete repair of tetralogy of Fallot. Cardiopulmonary bypass was established by cannulating the right internal jugular vein and the ipsilateral common carotid artery. The aneurysm was then excised and the right ventricular outflow tract reconstructed by direct sutures.