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Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies
Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies Ravi K. Ghanta, MD, Subroto Paul, MD, and Gregory S. Couper, MD Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
We report our approach to an unusual case of a 64-year-old man with multiple coronary artery aneurysms (CAAs) of the right, left anterior descending, and ramus coronary arteries. The right CAA was unusually large in size (measuring 5.5 cm). The aneurysms were obstructive, resulting in ischemic heart disease and heart failure. Multiple surgical techniques have been proposed to approach CAAs; however the ideal treatment strategy is poorly defined. This patient underwent successful revascularization using a combination of strategies, including aneurysm ligation, interposition reversed saphenous vein grafting, and bypass grafting. Surgical approach should be determined by aneurysm size, presence of branching vessels, and degree of stenosis. (Ann Thorac Surg 2007;84:e10 –1) © 2007 by The Society of Thoracic Surgeons
C
oronary artery aneurysms (CAAs) are encountered in approximately 5% of patients who present for coronary angiography [1]. Multiple aneurysms and giant (greater than 5 cm) aneurysms are even more rare [2]. The CAA is most commonly due to atherosclerosis and requires surgical intervention when significant stenosis results in myocardial ischemia. We present our approach to surgical revascularization in an elderly patient with multiple obstructive CAAs that resulted in ischemic heart disease and heart failure using a combination of surgical techniques. We review the surgical options for CAA and illustrate how the physical characteristics of the aneurysm should determine the surgical approach. A 64-year-old man with a history of coronary artery disease and myocardial infarction presented with complaints of dyspnea on exertion and chest pain. Thallium scintigraphy revealed anterolateral ischemia with significant ventricular dysfunction and an ejection fraction of 35%. Subsequent coronary angiography identified a 1-cm proximal aneurysm of the left anterior descending (LAD) artery with a distal 60% stenosis, a proximal 3-cm aneurysm of the ramus with a distal 60% stenosis, and a 5.5-cm aneurysm of the right coronary artery (RCA), with poor visualization of branch vessels. Echocardiography revealed moderate (2⫹) mitral regurgitation, left atrial enlargement, pulmonary artery hypertension, and moderate functional tricuspid regurgitation. The patient was taken to the operating room for surgical revascularization and valve repair. Examination of the outer surface of the heart confirmed the Accepted for publication April 5, 2007. Address correspondence to Dr Ghanta, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Intraoperative photograph of giant right coronary artery (RCA) aneurysm measuring 5.5 ⫻ 4.8 cm.
angiographic findings of large aneurysms of the RCA, LAD, and ramus (Fig 1). In addition, multiple smaller aneurysms of the RCA were identified extending to the posterior heart. The patient was placed on cardiopulmonary bypass and the aorta was cross clamped. Five hundred mL of antegrade and retrograde cold-blood cardioplegia was administered through the aortic root and coronary sinus, and then periodically throughout the cross-clamp period. The giant RCA aneurysm was marsupialized, revealing a well-defined proximal neck that was widely patent backward into the aorta and two small ventricular free wall branches (Fig 2). An interposition reversed saphenous vein graft was placed from the proximal RCA just as it entered the aneurysm to the RCA wall to perfuse both of the ventricular free wall branches. The distal aneurysm opening was oversewn and the excess aneursym wall was resected. A vein graft bypass from the aorta to the posterior descending artery was also performed due to distal obstructive lesions. The ramus aneurysm was opened and no discernible branches were identified. The proximal and distal aneursym ends were oversewn and a vein graft was placed between the aorta and the distal ramus. The LAD aneurysm was focal and small and we elected to not open the aneurysm. A left internal mammary artery to the LAD bypass and a vein graft to D1 was performed to bypass the obstructive lesions. The mitral valve was inspected and found to be morphologically normal, but with annular dilation and geometric alteration due to an old myocardial infarction. Given the chronic ischemic mitral regurgitation, a number 30 Geoform ring (Edwards Lifesciences, Irvine, CA) was implanted to repair the mitral annulus. The patient was weaned successfully from cardiopulmonary bypass with inotropic support, which he continued to require for 5 days postoperatively. His prolonged inotropic requirement may have been due to his pre-existing ventricular dysfunction and extensive atherosclerotic disease, which may have affected the delivery and efficacy of cardioplegia. He was discharged from the intensive care unit on 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.04.023
Ann Thorac Surg 2007;84:e10 –1
CASE REPORT GHANTA ET AL REVASCULARIZATION OF CORONARY ARTERY ANEURYSMS
e11
eurysm resection with direct end-to-end anastomosis, and reverse saphenous interposition grafting [5–7]. Endovascular approaches, such as intraluminal stenting and coil embolization have also been performed [8]. The primary goal of any surgical repair for CAA is restoration of blood flow and elimination of spontaneous rupture risk, usually by excision of the aneurysm. Our case presents a patient with multiple obstructive CAAs of different sizes and configurations. Thus we used a combination of repair techniques. The risk of aneurysm rupture is related to size, as larger aneurysms have higher wall stress by the Law of Laplace. Thus large (⬎1 cm) aneurysms require resection and small aneurysms can be observed. The risk of aneurysm resection includes disruption of flow to branching vessels and myocardial ischemia. All large aneurysms should be marsupialized and inspected for branching vessels. If significant branching vessels are found, an interposition graft may used to perfuse these branches as we did in this case for the giant RCA aneurysm. If no branching vessels are present, proximal or distal ligation with bypass grafting is appropriate. In conclusion, the surgical approach to CAA should be determined by the physical characteristics of the aneurysm, including size, presence of branching vessels or fistula, and degree of obstruction. Successful revascularization may be performed in patients with ischemic heart disease and multiple CAAs. Fig 2. Marsupialized right coronary artery (RCA) aneurysm. The proximal and distal openings and two ventricular free wall branches were seen.
postoperative day 8 and from the hospital on postoperative day 11, after an unremarkable hospital course. Six months postoperatively, he continues to do well.
Comment The CAA was first described postmortem by Morgagni [3] in 1761. Because CAA is a rare finding, no consensus surgical approach has been determined. Risks of CAA include spontaneous rupture, thrombosis, fistula formation, and myocardial ischemia [4]. Typically CAAs are repaired during coronary bypass grafting for ischemic heart disease, and multiple surgical techniques have been described including proximal and distal ligation of the aneurysm with coronary artery bypass grafting, an-
References 1. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134 – 8. 2. Mawatari T, Koshino T, Morishita K, et al. Successful surgical treatment of giant coronary artery aneurysm with fistula. Ann Thorac Surg 2000;70:1394 –7. 3. Morgagni JB. The seats and causes of diseases investigated by anatomy. Venice, Italy: Ex typographia Remondiniana; 1761: Epis 27, Art 28. 4. Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997;40:77– 84. 5. Vijayanagar R, Shafii E, DeSantis M, et al. Surgical treatment of coronary aneurysms with and without rupture. J Thorac Cardiovasc Surg 1994;107:1532–5. 6. Westaby S, Vaccari G, Katsumata T. Direct repair of giant right coronary aneurysm. Ann Thorac Surg 1999;68:1401–3. 7. Firstenberg MS, Azoury F, Lytle BW, et al. Interposition vein graft for giant coronary aneurysm repair. Ann Thorac Surg 2000;70:1397– 8. 8. Peterson MA, Monsein LH, Dangas G, et al. Percutaneous transcatheter management of giant coronary aneurysms. Circulation 1999;100:e8 –11.
We report our approach to an unusual case of a 64-year-old man with multiple coronary artery aneurysms (CAAs) of the right, left anterior descending, and ramus coronary arteries. The right CAA was unusually large in size (measuring 5.5 cm). The aneurysms were obstructive, resulting in ischemic heart disease and heart failure. Multiple surgical techniques have been proposed to approach CAAs; however the ideal treatment strategy is poorly defined. This patient underwent successful revascularization using a combination of strategies, including aneurysm ligation, interposition reversed saphenous vein grafting, and bypass grafting. Surgical approach should be determined by aneurysm size, presence of branching vessels, and degree of stenosis. (Ann Thorac Surg 2007;84:e10 –1) © 2007 by The Society of Thoracic Surgeons
C
oronary artery aneurysms (CAAs) are encountered in approximately 5% of patients who present for coronary angiography [1]. Multiple aneurysms and giant (greater than 5 cm) aneurysms are even more rare [2]. The CAA is most commonly due to atherosclerosis and requires surgical intervention when significant stenosis results in myocardial ischemia. We present our approach to surgical revascularization in an elderly patient with multiple obstructive CAAs that resulted in ischemic heart disease and heart failure using a combination of surgical techniques. We review the surgical options for CAA and illustrate how the physical characteristics of the aneurysm should determine the surgical approach. A 64-year-old man with a history of coronary artery disease and myocardial infarction presented with complaints of dyspnea on exertion and chest pain. Thallium scintigraphy revealed anterolateral ischemia with significant ventricular dysfunction and an ejection fraction of 35%. Subsequent coronary angiography identified a 1-cm proximal aneurysm of the left anterior descending (LAD) artery with a distal 60% stenosis, a proximal 3-cm aneurysm of the ramus with a distal 60% stenosis, and a 5.5-cm aneurysm of the right coronary artery (RCA), with poor visualization of branch vessels. Echocardiography revealed moderate (2⫹) mitral regurgitation, left atrial enlargement, pulmonary artery hypertension, and moderate functional tricuspid regurgitation. The patient was taken to the operating room for surgical revascularization and valve repair. Examination of the outer surface of the heart confirmed the Accepted for publication April 5, 2007. Address correspondence to Dr Ghanta, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Intraoperative photograph of giant right coronary artery (RCA) aneurysm measuring 5.5 ⫻ 4.8 cm.
angiographic findings of large aneurysms of the RCA, LAD, and ramus (Fig 1). In addition, multiple smaller aneurysms of the RCA were identified extending to the posterior heart. The patient was placed on cardiopulmonary bypass and the aorta was cross clamped. Five hundred mL of antegrade and retrograde cold-blood cardioplegia was administered through the aortic root and coronary sinus, and then periodically throughout the cross-clamp period. The giant RCA aneurysm was marsupialized, revealing a well-defined proximal neck that was widely patent backward into the aorta and two small ventricular free wall branches (Fig 2). An interposition reversed saphenous vein graft was placed from the proximal RCA just as it entered the aneurysm to the RCA wall to perfuse both of the ventricular free wall branches. The distal aneurysm opening was oversewn and the excess aneursym wall was resected. A vein graft bypass from the aorta to the posterior descending artery was also performed due to distal obstructive lesions. The ramus aneurysm was opened and no discernible branches were identified. The proximal and distal aneursym ends were oversewn and a vein graft was placed between the aorta and the distal ramus. The LAD aneurysm was focal and small and we elected to not open the aneurysm. A left internal mammary artery to the LAD bypass and a vein graft to D1 was performed to bypass the obstructive lesions. The mitral valve was inspected and found to be morphologically normal, but with annular dilation and geometric alteration due to an old myocardial infarction. Given the chronic ischemic mitral regurgitation, a number 30 Geoform ring (Edwards Lifesciences, Irvine, CA) was implanted to repair the mitral annulus. The patient was weaned successfully from cardiopulmonary bypass with inotropic support, which he continued to require for 5 days postoperatively. His prolonged inotropic requirement may have been due to his pre-existing ventricular dysfunction and extensive atherosclerotic disease, which may have affected the delivery and efficacy of cardioplegia. He was discharged from the intensive care unit on 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.04.023
Ann Thorac Surg 2007;84:e10 –1
CASE REPORT GHANTA ET AL REVASCULARIZATION OF CORONARY ARTERY ANEURYSMS
e11
eurysm resection with direct end-to-end anastomosis, and reverse saphenous interposition grafting [5–7]. Endovascular approaches, such as intraluminal stenting and coil embolization have also been performed [8]. The primary goal of any surgical repair for CAA is restoration of blood flow and elimination of spontaneous rupture risk, usually by excision of the aneurysm. Our case presents a patient with multiple obstructive CAAs of different sizes and configurations. Thus we used a combination of repair techniques. The risk of aneurysm rupture is related to size, as larger aneurysms have higher wall stress by the Law of Laplace. Thus large (⬎1 cm) aneurysms require resection and small aneurysms can be observed. The risk of aneurysm resection includes disruption of flow to branching vessels and myocardial ischemia. All large aneurysms should be marsupialized and inspected for branching vessels. If significant branching vessels are found, an interposition graft may used to perfuse these branches as we did in this case for the giant RCA aneurysm. If no branching vessels are present, proximal or distal ligation with bypass grafting is appropriate. In conclusion, the surgical approach to CAA should be determined by the physical characteristics of the aneurysm, including size, presence of branching vessels or fistula, and degree of obstruction. Successful revascularization may be performed in patients with ischemic heart disease and multiple CAAs. Fig 2. Marsupialized right coronary artery (RCA) aneurysm. The proximal and distal openings and two ventricular free wall branches were seen.
postoperative day 8 and from the hospital on postoperative day 11, after an unremarkable hospital course. Six months postoperatively, he continues to do well.
Comment The CAA was first described postmortem by Morgagni [3] in 1761. Because CAA is a rare finding, no consensus surgical approach has been determined. Risks of CAA include spontaneous rupture, thrombosis, fistula formation, and myocardial ischemia [4]. Typically CAAs are repaired during coronary bypass grafting for ischemic heart disease, and multiple surgical techniques have been described including proximal and distal ligation of the aneurysm with coronary artery bypass grafting, an-
References 1. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134 – 8. 2. Mawatari T, Koshino T, Morishita K, et al. Successful surgical treatment of giant coronary artery aneurysm with fistula. Ann Thorac Surg 2000;70:1394 –7. 3. Morgagni JB. The seats and causes of diseases investigated by anatomy. Venice, Italy: Ex typographia Remondiniana; 1761: Epis 27, Art 28. 4. Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997;40:77– 84. 5. Vijayanagar R, Shafii E, DeSantis M, et al. Surgical treatment of coronary aneurysms with and without rupture. J Thorac Cardiovasc Surg 1994;107:1532–5. 6. Westaby S, Vaccari G, Katsumata T. Direct repair of giant right coronary aneurysm. Ann Thorac Surg 1999;68:1401–3. 7. Firstenberg MS, Azoury F, Lytle BW, et al. Interposition vein graft for giant coronary aneurysm repair. Ann Thorac Surg 2000;70:1397– 8. 8. Peterson MA, Monsein LH, Dangas G, et al. Percutaneous transcatheter management of giant coronary aneurysms. Circulation 1999;100:e8 –11.