- Email: [email protected]
Surgical treatment of coronary artery aneurysm with rupture into the right atrium
Surgical treatment of coronary artery aneurysm with rupture into the right atrium Considering the increasing number of patients with chest pain who undergo routine coronary artery arteriography, coronary artery aneurysm may be found more frequently. To know how to manage these aneurysms, we must understand their possible complications. The aneurysms can produce symptoms of angina or acute myocardial infarction by total thrombosis of the aneurysm and vessel, embolism to the distal vessel, or progressive enlargement and encroachment upon the distal vessel until it is occluded. Moreover, the.aneurysm may enlarge and rupture into the free pericardium or produce a fistula by eroding into a chamber of the heart. The case described herein may represent the first reported case of a coronary artery aneurysm eroding into a cardiac chamber and causing an arteriovenous fistula. The treatment of choice is resection of the aneurysm, closure of the fistula, and re-establishment of continuity of the distal coronary artery with a saphenous vein bypass graft. Laman A. Gray, Jr., M.D., and Daniel E. McMartin, M.D., Louisville, Ky.
Although coronary artery aneurysms were first described by Morgagni in 1761 1 during postmortem studies, not until 1967 was the first report of premortem diagnosis of coronary artery aneurysm published.' To date, approximately 100 cases of coronary artery aneurysms have been reported in the English literature. A few of these patients have been operated upon successfully with saphenous vein interposition. As coronary angiocardiography becomes more common, more cases of coronary artery aneurysm may be recognized. An understanding of the possible complications that can arise secondary to these aneurysms is therefore important. Once complications are known, therapeutic modalities can be established.
Case report A 54-year-old woman had vague chest pains suggesting angina pectoris for 3 months before admission to the hospital. During the week preceding admission the chest pain had become much more severe, occurring both at rest and with exercise. On admission she had symptoms of congestive heart failure. From the Section of Thoracic and Cardiovascular Surgery of the Department of Surgery and the Section of Cardiology of the Department of Medicine, the University of Louisville School of Medicine, Health Sciences Center, Louisville, Ky. 40201. Received for publication March 21, 1977. Accepted for publication April 14, 1977. Requests for reprints should be addressed to the Department of Surgery.
Pertinent physical findings at the time of admission were limited to a Grade 3/6 holosystolic murmur loudest along the upper left sternal border. The electrocardiogram was within normal limits. Chest x-ray examination disclosed a mass in the right superior part of the mediastinum and a second mass located along the right heart border (Fig. IA and IB). Review of a chest x-ray film taken 3 years earlier showed that the right superior mediastinal mass was unchanged; however, the mass along the right heart border was new. The clinical impression was that the patient had preinfarction angina. Cardiac catheterization demonstrated a very large aneurysm near the origin of the right coronary artery; the lesion had eroded into the right atrium and formed an arteriovenous fistula (Figs. 2 and 3). No evidence of significant occlusive disease in the coronary arteries was present. The cineangiogram of the left coronary artery showed that the proximal left anterior descending and the proximal circumflex coronary arteries were aneurysmal (Fig. 4). At the time of operation, a very large pseudoaneurysm approximately 6 ern. in diameter was located 3 em. from the origin of the right coronary artery. The pseudoaneurysm extended superiorly between the right ventricle and aorta and inferiorly toward the right atrium (Fig. 5). The top of the pseudoaneurysm was extremely thin. The right atrium was quite tense, and a continuous thrill could be palpated over the entire atrium. The patient was placed on cardiopulmonary bypass and cooled to 28° C. The aorta was cross-clamped, and iced Ringer's lactate solution at 4° C. was flushed over the heart. The pseudoaneurysm was entered. The origin of the pseudoaneurysm was identified approximately 3 cm. from the origin of the right coronary artery. There was a 6 mm. hole, entering the pseudoaneurysm, in the lateral side of the right coronary artery (Fig. 6). Examination of the inside of the
455
The Journal of Thoracic and Cardiovascular Surgery
45 6 Gray and McMartin
Fig. 1. Posteroanterior (A) and lateral (B) chest x-ray films. A mass is located along the right upper heart border near the superior aspect of the right atrium and the aortic root. pseudoaneurysm disclosed a 1 cm. connection with the superior aspect of the right atrium. This was located approximately 4 em. inferior to the orifice in the right coronary artery. The fistula leading to the right atrium was closed with interrupted, pledgeted sutures. The communication with the right coronary artery was also closed with pledgeted sutures. Continuity of the distal right coronary artery was established with an aorta-coronary artery bypass graft (Fig. 7). Histologic examination of the aneurysm demonstrated fibrous connective tissue indicative of a pseudoaneurysm. Postoperatively, the patient has done quite well. She has had no symptoms of recurrent angina or cardiac failure.
Discussion
Fig. 2. An aortic root injection shows aneurysmal dilatation of the right coronary artery with a very large pseudoaneurysm arising from it (outlined by arrows).
With the advent of coronary arteriography, coronary artery aneurysms are being diagnosed more frequently during life. Sayegh and associates" reviewed 200 coronary cinearteriograms performed at the Cleveland Veterans Administration Hospital and found one instance of a coronary artery aneurysm. Benchimol and colleagues" described two cases of multiple coronary artery aneurysms in a series of over 2,000 selective coronary cineangiograms and one additional instance of a single coronary artery aneurysm. More recently, Olin and others" found five cases of coronary artery
Volume 74 Number3 September, 19n
Coronary artery aneurysm
45 7
Fig. 3. A moreselectiveinjection showsthe fistulous communication (arrows) between the dilatedright coronary artery and the pseudoaneurysm.
Fig. 4. Selective injection of the left main coronary artery demonstrates aneurysmal dilatation of both the proximal left anterior descending coronary artery and the proximal circumflex coronary artery.
aneurysms in a consecutive series of 273 arteriograms, an incidence of 1.8 percent. In 1968, Kalke and Edwards" presented a classification of coronary artery aneurysms. Localized aneurysms are either congenital or acquired. Although acquired aneurysms occur secondary to arteriosclerosis, infection, trauma, neoplasm, or arteriovenous fistula, arteriosclerosis is the principal factor in the genesis of localized coronary artery aneurysms. Daoud and co-workers? found that 52 percent of all coronary artery aneurysms are secondary to arte-
riosclerosis. Congenital aneurysms accounted for 17 percent of the total, mycotic/embolic aneurysms for 11 percent, dissecting aneurysms for 11 percent, and syphilitic aneurysms for 4 percent; the remaining 5 percent resulted from vasculitis, trauma, and unknown causes. Among eight patients with localized coronary artery aneurysm described by Kalke and Edwards , 6 arteriosclerosis was the causative factor in six. With weakening of the arterial media secondary to the arteriosclerosis, it is easy to understand why aneurysms
45 8 Gray and McMartin
Fig. 5. A large pseudoaneurysm was present, located be-
tween the aortic root and the right atrium.
Fig. 6. Opening the aneurysm disclosed a 6 mm. hole in the lateral aspect of the right coronary artery. The aneurysm had eroded into the right atrium forming an arteriovenous fistula.
form; in fact, it is difficult to understand why they are not more common. In three of the six patients with arteriosclerotic aneurysms, death was attributed directly to the aneurysms. Thrombosis caused partial or complete occlusion of the lumen and resulted in myocardial infarction. Of the six arteriosclerotic aneurysms, four were solitary. The right coronary artery was involved in three instances and the left main coronary artery in one. Two patients had multiple aneurysms involving both the right coronary artery and the left anterior descending coronary artery.
The Journal of Thoracic and Cardiovascular Surgery
Fig. 7. The fistula betweenthe pseudoaneurysm and the right atrium was closed with interrupted pledgeted sutures. Similarly, the fistula to coronary artery was closed with pledgeted sutures. Continuity of the vessel was established with a saphenous vein bypass graft.
The symptoms of coronary artery aneurysms are usually referrable to the patient's primary disease. Patients with coronary artery aneurysm have symptoms related to arteriosclerotic coronary artery disease: acute myocardial infarction, angina pectoris, or congestive heart failure. Occasionally a patient will die suddenly from rupture of the aneurysm. Myocardial ischemia may be secondary to a steal phenomena." Bjork and Bjork" measured flow through a coronary artery aneurysm with an electromagnetic flow probe and found a coronary steal attributable to blood flow into a large, relaxed aneurysm during diastole and retrograde coronary flow during systole. Another cause of myocardial ischemia is microemboli forming in the aneurysms. 8 The third possible cause is occlusive arteriosclerotic coronary artery disease associated with coronary artery aneurysms. Thus patients with coronary artery aneurysms may have symptoms based on coronary artery disease with myocardial ischemia, embolization from the aneurysms, or a steal syndrome. In 1971, Ebert and associates" reported on the successful resection of the coronary artery aneurysm and re-establishment of continuity of the vessel with a saphenous vein graft. Their patient was a 31-year-old woman who had angina, weakness, and cardiomegaly. Cinearteriograms showed a coronary artery aneurysm of the circumflex coronary artery. Blood clots were present within the aneurysm along with markedly turbulent swirling flow. Her symptoms were secondary to
Volume 74 Number 3 September, 19n
small thrombi embolizing to the peripheral bed of the circumflex coronary artery. The aneurysm was resected and continuity of the vessels was re-established by interposition of a saphenous vein graft. PostoperativeIy, the patient did well. Ghahramani and associates" described a 32-yearold woman who had an acute myocardial infarction followed by angina pectoris. The cinearteriograms showed a calcified aneurysm at the origin of the left anterior descending coronary artery with total obstruction of the vessel. This patient was treated successfully with coronary artery bypass. Her symptoms were probably not secondary to embolization from the breakdown of thrombus within the aneurysm, because the entire course of the left anterior descending coronary artery and its branches appeared normal on postoperative cineangiogram. The patient's myocardial infarction and occlusion of the left anterior descending coronary artery were believed attributable either to gradual enlargement of the aneurysm, until its wall encroached on the proximal part of the vessel and occluded it by compression, or else to formation of a thrombus within the aneurysm, which gradually occluded the entire aneurysm and distal vessel. Wilson and colleagues'" presented a case of tight luminal stenosis at the proximal end of the large aneurysm in the left anterior descending coronary artery and suggested poststenotic dilatation as the cause or as a contributing factor. The right coronary artery was totally occluded; however, at operation it was also aneurysmal. After a bypass procedure, the patient initially did well. Whether the left anterior descending coronary artery should be ligated just distal to the aneurysm to prevent future embolization is not known; in this patient the vessel was not ligated distal to the aneurysm. Although the patient was placed on longterm anticoagulant therapy with sodium warfarin, she had an episode of angina 8 months after operation. These authors suggest that the angina may have resulted from embolization within the aneurysm. Because embolism to the distal portion of the left anterior descending coronary artery could be fatal, Wilson and associates'? believe ligation of the distal end of the aneurysm during a bypass operation may be preferable. Embolization can be prevented in some instances by excising the aneurysm and inserting an interposing vein graft. When this is not possible, the vessel probably should be ligated distal to the aneurysm. Long-term results following coronary artery bypass to aneurysms are not known. Mattern and associates!' described a case in which recurrent angina developed 18 months postoperatively. A repeat angiocardiogram
Coronary artery aneurysm
459
at that time demonstrated new aneurysmal dilatations of the posterior descending branch distal to a patent graft into the right coronary artery. There was also enlargement of an aneurysm in the nongrafted left coronary artery. This disconcerting observation suggests a diffuse structural defect of the coronary artery walls. Whether such a defect would be a major problem in managing this disease is not known. The case which we describe herein represents an unusual complication of coronary artery aneurysm. The woman had aneurysmal dilatation of both the right coronary artery and the proximal left anterior descending coronary artery. In the proximal right coronary artery, a large pseudoaneurysm formed. This aneurysm probably had been present for many years. As it enlarged, there was gradual erosion into the right atrium forming a fistula between the right coronary artery aneurysm and right atrium. The patient then began having symptoms of angina pectoris and congestive heart failure. The angina resulted from a steal phenomenon, because there was no evidence of thrombi within the aneurysm and no source of emboli to the distal right coronary artery. The aneurysm was not congenital because of the anatomy of the arteriovenous fistula. There was a 6 mm. defect, entering into a large pseudoaneurysm, in the lateral wall of the proximal right coronary artery. Approximately 4 em. from the defect in the coronary artery, a second fistula led to the right atrium. The aneurysm had eroded into the atrium producing the fistula. The aneurysm and fistula were repaired by resecting the aneurysm, closing the fistula into the right coronary artery and the fistula into the right atrium, and re-establishing continuity of the distal right coronary artery with a saphenous vein bypass graft. REFERENCES Jarcho, S.: Bougon on Coronary Aneurysm (1812), Am. J. Cardio\. 24: 551, 1969. 2 Bjork, V. 0., and Bjork, L.: Intramural Coronary Artery Aneurysm: A Coronary Artery Steal Syndrome, J. THORAC. CARDIOVASC. SURG.
54: 50, 1967.
3 Sayegh, S., Adad, W., and Macleod, C. A.: Multiple Aneurysms of the Coronary Arteries, Am. Heart. J. 76: 266, 1968.
4 Benchimol, A., Harris, C. L., Mori, K., and Desser, K. B.: Multiple Aneurysms of the Coronary Arteries: Demonstration by Selective Coronary Arteriography, Ariz. Med. 30: 705, 1973. 5 Olin, R., Duval, D. L., and Dickson, D. N.: Atherosclerotic Coronary-Artery Aneurysms: Report of Five Cases Diagnosed by Cine-coronary Arteriography, Minn. Med. 59: 157, 1976.
460 Gray and McMartin
6 Kalke, B., and Edwards, 1. E.: Localized Aneurysms of the Coronary Arteries, Angiology 19: 460, 1968. 7 Daoud, A. S., Pankin, D., Tulgan, H., and Florentin, R. A.: Aneurysm of the Coronary Artery: Report of Ten Cases and Review of Literature, Am. J. Cardio\. 11: 228, 1963. 8 Ebert, P. A., Peter, R. H., Gunnells, J. c., and Sabiston, D. C., Jr.: Resecting and Grafting of Coronary Artery Aneurysm, Circulation 43: 593, 1971. 9 Ghahramani, A., Iyengar, R., Cunha, D., Jude, J., and Sommer, L.: Myocardial Infarction Due to Congenital
The Journal of Thoracic and Cardiovascular Surgery
Coronary Arterial Aneurysm (With Successful Saphenous Vein Bypass Graft), Am. J. Cardio\. 29: 863, 1972. 10 Wilson, C. S., Weaver, W. F., and Forker, A. D.: Bilateral Arteriosclerotic Coronary Arterial Aneurysms Successfully Treated With Saphenous Vein Bypass Grafting, Am. 1. Cardio\. 35: 315, 1975. II Mattern, A. L., Baker, W. P., McHale, J. J., and Lee, D. E.: Congenital Coronary Aneurysms With Angina Pectoris and Myocardial Infarction Treated With Saphenous Vein Bypass Graft, Am. J. Cardio\. 30: 906,1972.
Although coronary artery aneurysms were first described by Morgagni in 1761 1 during postmortem studies, not until 1967 was the first report of premortem diagnosis of coronary artery aneurysm published.' To date, approximately 100 cases of coronary artery aneurysms have been reported in the English literature. A few of these patients have been operated upon successfully with saphenous vein interposition. As coronary angiocardiography becomes more common, more cases of coronary artery aneurysm may be recognized. An understanding of the possible complications that can arise secondary to these aneurysms is therefore important. Once complications are known, therapeutic modalities can be established.
Case report A 54-year-old woman had vague chest pains suggesting angina pectoris for 3 months before admission to the hospital. During the week preceding admission the chest pain had become much more severe, occurring both at rest and with exercise. On admission she had symptoms of congestive heart failure. From the Section of Thoracic and Cardiovascular Surgery of the Department of Surgery and the Section of Cardiology of the Department of Medicine, the University of Louisville School of Medicine, Health Sciences Center, Louisville, Ky. 40201. Received for publication March 21, 1977. Accepted for publication April 14, 1977. Requests for reprints should be addressed to the Department of Surgery.
Pertinent physical findings at the time of admission were limited to a Grade 3/6 holosystolic murmur loudest along the upper left sternal border. The electrocardiogram was within normal limits. Chest x-ray examination disclosed a mass in the right superior part of the mediastinum and a second mass located along the right heart border (Fig. IA and IB). Review of a chest x-ray film taken 3 years earlier showed that the right superior mediastinal mass was unchanged; however, the mass along the right heart border was new. The clinical impression was that the patient had preinfarction angina. Cardiac catheterization demonstrated a very large aneurysm near the origin of the right coronary artery; the lesion had eroded into the right atrium and formed an arteriovenous fistula (Figs. 2 and 3). No evidence of significant occlusive disease in the coronary arteries was present. The cineangiogram of the left coronary artery showed that the proximal left anterior descending and the proximal circumflex coronary arteries were aneurysmal (Fig. 4). At the time of operation, a very large pseudoaneurysm approximately 6 ern. in diameter was located 3 em. from the origin of the right coronary artery. The pseudoaneurysm extended superiorly between the right ventricle and aorta and inferiorly toward the right atrium (Fig. 5). The top of the pseudoaneurysm was extremely thin. The right atrium was quite tense, and a continuous thrill could be palpated over the entire atrium. The patient was placed on cardiopulmonary bypass and cooled to 28° C. The aorta was cross-clamped, and iced Ringer's lactate solution at 4° C. was flushed over the heart. The pseudoaneurysm was entered. The origin of the pseudoaneurysm was identified approximately 3 cm. from the origin of the right coronary artery. There was a 6 mm. hole, entering the pseudoaneurysm, in the lateral side of the right coronary artery (Fig. 6). Examination of the inside of the
455
The Journal of Thoracic and Cardiovascular Surgery
45 6 Gray and McMartin
Fig. 1. Posteroanterior (A) and lateral (B) chest x-ray films. A mass is located along the right upper heart border near the superior aspect of the right atrium and the aortic root. pseudoaneurysm disclosed a 1 cm. connection with the superior aspect of the right atrium. This was located approximately 4 em. inferior to the orifice in the right coronary artery. The fistula leading to the right atrium was closed with interrupted, pledgeted sutures. The communication with the right coronary artery was also closed with pledgeted sutures. Continuity of the distal right coronary artery was established with an aorta-coronary artery bypass graft (Fig. 7). Histologic examination of the aneurysm demonstrated fibrous connective tissue indicative of a pseudoaneurysm. Postoperatively, the patient has done quite well. She has had no symptoms of recurrent angina or cardiac failure.
Discussion
Fig. 2. An aortic root injection shows aneurysmal dilatation of the right coronary artery with a very large pseudoaneurysm arising from it (outlined by arrows).
With the advent of coronary arteriography, coronary artery aneurysms are being diagnosed more frequently during life. Sayegh and associates" reviewed 200 coronary cinearteriograms performed at the Cleveland Veterans Administration Hospital and found one instance of a coronary artery aneurysm. Benchimol and colleagues" described two cases of multiple coronary artery aneurysms in a series of over 2,000 selective coronary cineangiograms and one additional instance of a single coronary artery aneurysm. More recently, Olin and others" found five cases of coronary artery
Volume 74 Number3 September, 19n
Coronary artery aneurysm
45 7
Fig. 3. A moreselectiveinjection showsthe fistulous communication (arrows) between the dilatedright coronary artery and the pseudoaneurysm.
Fig. 4. Selective injection of the left main coronary artery demonstrates aneurysmal dilatation of both the proximal left anterior descending coronary artery and the proximal circumflex coronary artery.
aneurysms in a consecutive series of 273 arteriograms, an incidence of 1.8 percent. In 1968, Kalke and Edwards" presented a classification of coronary artery aneurysms. Localized aneurysms are either congenital or acquired. Although acquired aneurysms occur secondary to arteriosclerosis, infection, trauma, neoplasm, or arteriovenous fistula, arteriosclerosis is the principal factor in the genesis of localized coronary artery aneurysms. Daoud and co-workers? found that 52 percent of all coronary artery aneurysms are secondary to arte-
riosclerosis. Congenital aneurysms accounted for 17 percent of the total, mycotic/embolic aneurysms for 11 percent, dissecting aneurysms for 11 percent, and syphilitic aneurysms for 4 percent; the remaining 5 percent resulted from vasculitis, trauma, and unknown causes. Among eight patients with localized coronary artery aneurysm described by Kalke and Edwards , 6 arteriosclerosis was the causative factor in six. With weakening of the arterial media secondary to the arteriosclerosis, it is easy to understand why aneurysms
45 8 Gray and McMartin
Fig. 5. A large pseudoaneurysm was present, located be-
tween the aortic root and the right atrium.
Fig. 6. Opening the aneurysm disclosed a 6 mm. hole in the lateral aspect of the right coronary artery. The aneurysm had eroded into the right atrium forming an arteriovenous fistula.
form; in fact, it is difficult to understand why they are not more common. In three of the six patients with arteriosclerotic aneurysms, death was attributed directly to the aneurysms. Thrombosis caused partial or complete occlusion of the lumen and resulted in myocardial infarction. Of the six arteriosclerotic aneurysms, four were solitary. The right coronary artery was involved in three instances and the left main coronary artery in one. Two patients had multiple aneurysms involving both the right coronary artery and the left anterior descending coronary artery.
The Journal of Thoracic and Cardiovascular Surgery
Fig. 7. The fistula betweenthe pseudoaneurysm and the right atrium was closed with interrupted pledgeted sutures. Similarly, the fistula to coronary artery was closed with pledgeted sutures. Continuity of the vessel was established with a saphenous vein bypass graft.
The symptoms of coronary artery aneurysms are usually referrable to the patient's primary disease. Patients with coronary artery aneurysm have symptoms related to arteriosclerotic coronary artery disease: acute myocardial infarction, angina pectoris, or congestive heart failure. Occasionally a patient will die suddenly from rupture of the aneurysm. Myocardial ischemia may be secondary to a steal phenomena." Bjork and Bjork" measured flow through a coronary artery aneurysm with an electromagnetic flow probe and found a coronary steal attributable to blood flow into a large, relaxed aneurysm during diastole and retrograde coronary flow during systole. Another cause of myocardial ischemia is microemboli forming in the aneurysms. 8 The third possible cause is occlusive arteriosclerotic coronary artery disease associated with coronary artery aneurysms. Thus patients with coronary artery aneurysms may have symptoms based on coronary artery disease with myocardial ischemia, embolization from the aneurysms, or a steal syndrome. In 1971, Ebert and associates" reported on the successful resection of the coronary artery aneurysm and re-establishment of continuity of the vessel with a saphenous vein graft. Their patient was a 31-year-old woman who had angina, weakness, and cardiomegaly. Cinearteriograms showed a coronary artery aneurysm of the circumflex coronary artery. Blood clots were present within the aneurysm along with markedly turbulent swirling flow. Her symptoms were secondary to
Volume 74 Number 3 September, 19n
small thrombi embolizing to the peripheral bed of the circumflex coronary artery. The aneurysm was resected and continuity of the vessels was re-established by interposition of a saphenous vein graft. PostoperativeIy, the patient did well. Ghahramani and associates" described a 32-yearold woman who had an acute myocardial infarction followed by angina pectoris. The cinearteriograms showed a calcified aneurysm at the origin of the left anterior descending coronary artery with total obstruction of the vessel. This patient was treated successfully with coronary artery bypass. Her symptoms were probably not secondary to embolization from the breakdown of thrombus within the aneurysm, because the entire course of the left anterior descending coronary artery and its branches appeared normal on postoperative cineangiogram. The patient's myocardial infarction and occlusion of the left anterior descending coronary artery were believed attributable either to gradual enlargement of the aneurysm, until its wall encroached on the proximal part of the vessel and occluded it by compression, or else to formation of a thrombus within the aneurysm, which gradually occluded the entire aneurysm and distal vessel. Wilson and colleagues'" presented a case of tight luminal stenosis at the proximal end of the large aneurysm in the left anterior descending coronary artery and suggested poststenotic dilatation as the cause or as a contributing factor. The right coronary artery was totally occluded; however, at operation it was also aneurysmal. After a bypass procedure, the patient initially did well. Whether the left anterior descending coronary artery should be ligated just distal to the aneurysm to prevent future embolization is not known; in this patient the vessel was not ligated distal to the aneurysm. Although the patient was placed on longterm anticoagulant therapy with sodium warfarin, she had an episode of angina 8 months after operation. These authors suggest that the angina may have resulted from embolization within the aneurysm. Because embolism to the distal portion of the left anterior descending coronary artery could be fatal, Wilson and associates'? believe ligation of the distal end of the aneurysm during a bypass operation may be preferable. Embolization can be prevented in some instances by excising the aneurysm and inserting an interposing vein graft. When this is not possible, the vessel probably should be ligated distal to the aneurysm. Long-term results following coronary artery bypass to aneurysms are not known. Mattern and associates!' described a case in which recurrent angina developed 18 months postoperatively. A repeat angiocardiogram
Coronary artery aneurysm
459
at that time demonstrated new aneurysmal dilatations of the posterior descending branch distal to a patent graft into the right coronary artery. There was also enlargement of an aneurysm in the nongrafted left coronary artery. This disconcerting observation suggests a diffuse structural defect of the coronary artery walls. Whether such a defect would be a major problem in managing this disease is not known. The case which we describe herein represents an unusual complication of coronary artery aneurysm. The woman had aneurysmal dilatation of both the right coronary artery and the proximal left anterior descending coronary artery. In the proximal right coronary artery, a large pseudoaneurysm formed. This aneurysm probably had been present for many years. As it enlarged, there was gradual erosion into the right atrium forming a fistula between the right coronary artery aneurysm and right atrium. The patient then began having symptoms of angina pectoris and congestive heart failure. The angina resulted from a steal phenomenon, because there was no evidence of thrombi within the aneurysm and no source of emboli to the distal right coronary artery. The aneurysm was not congenital because of the anatomy of the arteriovenous fistula. There was a 6 mm. defect, entering into a large pseudoaneurysm, in the lateral wall of the proximal right coronary artery. Approximately 4 em. from the defect in the coronary artery, a second fistula led to the right atrium. The aneurysm had eroded into the atrium producing the fistula. The aneurysm and fistula were repaired by resecting the aneurysm, closing the fistula into the right coronary artery and the fistula into the right atrium, and re-establishing continuity of the distal right coronary artery with a saphenous vein bypass graft. REFERENCES Jarcho, S.: Bougon on Coronary Aneurysm (1812), Am. J. Cardio\. 24: 551, 1969. 2 Bjork, V. 0., and Bjork, L.: Intramural Coronary Artery Aneurysm: A Coronary Artery Steal Syndrome, J. THORAC. CARDIOVASC. SURG.
54: 50, 1967.
3 Sayegh, S., Adad, W., and Macleod, C. A.: Multiple Aneurysms of the Coronary Arteries, Am. Heart. J. 76: 266, 1968.
4 Benchimol, A., Harris, C. L., Mori, K., and Desser, K. B.: Multiple Aneurysms of the Coronary Arteries: Demonstration by Selective Coronary Arteriography, Ariz. Med. 30: 705, 1973. 5 Olin, R., Duval, D. L., and Dickson, D. N.: Atherosclerotic Coronary-Artery Aneurysms: Report of Five Cases Diagnosed by Cine-coronary Arteriography, Minn. Med. 59: 157, 1976.
460 Gray and McMartin
6 Kalke, B., and Edwards, 1. E.: Localized Aneurysms of the Coronary Arteries, Angiology 19: 460, 1968. 7 Daoud, A. S., Pankin, D., Tulgan, H., and Florentin, R. A.: Aneurysm of the Coronary Artery: Report of Ten Cases and Review of Literature, Am. J. Cardio\. 11: 228, 1963. 8 Ebert, P. A., Peter, R. H., Gunnells, J. c., and Sabiston, D. C., Jr.: Resecting and Grafting of Coronary Artery Aneurysm, Circulation 43: 593, 1971. 9 Ghahramani, A., Iyengar, R., Cunha, D., Jude, J., and Sommer, L.: Myocardial Infarction Due to Congenital
The Journal of Thoracic and Cardiovascular Surgery
Coronary Arterial Aneurysm (With Successful Saphenous Vein Bypass Graft), Am. J. Cardio\. 29: 863, 1972. 10 Wilson, C. S., Weaver, W. F., and Forker, A. D.: Bilateral Arteriosclerotic Coronary Arterial Aneurysms Successfully Treated With Saphenous Vein Bypass Grafting, Am. 1. Cardio\. 35: 315, 1975. II Mattern, A. L., Baker, W. P., McHale, J. J., and Lee, D. E.: Congenital Coronary Aneurysms With Angina Pectoris and Myocardial Infarction Treated With Saphenous Vein Bypass Graft, Am. J. Cardio\. 30: 906,1972.