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J Thorac Cardiovasc Surg 1994;107:1532-1535
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Surgical treatment of coronary aneurysms with and without rupture

Raghavendra Vijayanagar , MD, FACS, Esfandiar Shafii , MD, FACS, Marshall DeSantis , MD, FACS, Raymond S. Waters , MD, Akshay Desai , MD

Cardiovascular and Thoracic Surgery
Tampa General Hospital
Tampa, FL 33606

To The Editor:

Coronary artery bypass grafting (CABG) has been a well established surgical treatment for severe coronary artery disease (CAD). In several subsets of patients with severe left main CAD, CAD with severe left ventricular dysfunction, septugenarians and octogenerians, and elderly women, and other populations CABG has been well described.Go Go 1,2 As the progress of new methods of diagnoses and treatment of CAD has evolved and accelerated in the past decade, the surgical treatment also has taken on new dimensions.Go 3 The object of this letter is to present CABG in two patients with and without rupture of coronary aneurysms.

CASE 1
A 68-year-old white man was admitted to a peripheral hospital for a syncopal episode. This was his first episode and there was no significant contributory history except for chronic obstructive lung disease. An echocardiogram performed at that hospital in the emergency department revealed pericardial effusion with tamponade. Emergency pericardial window by a left thoracotomy revealed hemorrhagic effusion. The patient was immediately transferred to Tampa General Hospital. Computed tomography revealed a possible extracardiac mass compressing the right atrium. Coronary cineangiography revealed severe three-vessel CAD with a large, 7 to 8 cm aneurysm of the right coronary artery (RCA), a 3 cm aneurysm of the left anterior descending coronary artery (LAD), and a 2 to 3 cm aneurysm of the proximal circumflex coronary artery with total occlusion (Figs. 1 and 2). At operation there was evidence for hemorrhage, organized thrombus, and a large RCA aneurysm. A subtotal resection of the aneurysm, suture ligation of the RCA from within, and aneurysmorrhaphy were carried out (Figs. 3, 4, and 5). The LAD distal to the aneurysm was ligated and the patient had triple CABG with saphenous veins. The patient recovered and is doing well 11/2 years after operation.



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  		Fig. 1. Cinecoronary angiogram of RCA shows large aneurysm in its midportion.

 


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  		Fig. 2. Cinecoronary angiogram of left coronary artery shows aneurysm of LAD and total occlusion of circumflex with aneurysm formation.

 


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  		Fig. 3. Hemorrhagic mediastium. Aneurysm of RCA covered with blood and thrombus is seen (arrow).

 


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  		Fig. 4. Large aneurysm of RCA (arrow) lifted upward out of pericardial cavity.

 


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  		Fig. 5. Aneurysm of RCA is opened to show thrombus formation.

 
CASE 2
A 32-year-old white man had an inferior wall myocardial infarction. This was complicated by postinfarction angina and positive results of a stress test. Significant history included a renal transplant 4 years previously. Cardiac catheterization studies revealed left ventricular dysfunction and severe CAD including a large, 3 cm aneurysm of the LAD, including the left main coronary artery (Fig. 6). The patient underwent quadruple CABG including removal of thrombus, subtotal resection of the aneurysm with repair, distal ligation, and internal mammary artery bypass to the LAD. The patient is doing well 11/2 years after operation. Intensive prophylactic antibiotic therapy and intravenous treatment with immunosuppressive agents were administered throughout the preoperative and postoperative periods.



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  		Fig. 6. Large aneurysm of LAD involved left main coronary artery. Aneurysm was filled with thrombus.

 
We describe here two case reports: one case of coronary aneurysm involving the left main coronary artery and the other case dealing with a ruptured aneurysm of the RCA. True coronary artery aneurysms are rare, although prestenotic and poststenotic coronary dilatation and coronary artery ectasia are commonly seen in all age groups of patients. Most of the coronary aneurysms are atherosclerotic in nature,Go Go 3,4 although coronary aneurysms caused by trauma, inflammation, and congenital coronary aneurysms have been described.Go Go 3-5 The prevalence varies from 0.3% to 4.9%.Go Go 3-5 Treatment of coronary aneurysms has not been clearly defined until recently.Go 5 Tunick and coworkersGo 3 described surgical treatment of coronary aneurysms. Varied treatments, including total resection, partial resection, and ligation with concomitant CABG, have been described. The main complication of coronary aneurysm is distal embolization and myocardial infarction. Rupture is indeed rare.Go Go 3-5 We have described successful treatment for a large, ruptured aneurysm of the RCA that caused acute cardiac tamponade. Rare cases of thrombosed aneurysm of the coronary arteries have been autopsy findings described in textbooks or case reports.Go Go 3-5 Thorough review of the recent English-language literature has not provided any information regarding case reports of successful surgical treatment of large, ruptured aneurysm of the coronary artery.

References

  1. Vijayanagar R, Bognolo D, Eckstein P, Toole J, Natarajan P, Harrison E. Surgical management of main left coronary artery disease. J Fla Med Assoc 1980;67:1002-4.
  2. Vijayanagar R, Bognolo D, Eckstein P, et al. Safety and efficacy of internal mammary artery grafts for left main coronary artery disease. J Cardiovasc Surg 1987;28:576-80. [Medline]
  3. Tunick PA, Slater J, Kronzon I, Glassman E. Discrete atherosclerotic coronary artery aneurysms: a study of 20 patients. J Am Coll Cardiol 1990;15:279-82. [Abstract]
  4. Anabtawi IN, de Leon JA. Arterisclerotic aneurysms of the coronary artery. J THORAC CARDIOVASC SURG 1974;68:226-8. [Medline]
  5. Bricker DL, Rittman DV. Arteriosclerotic aneurysms of the coronary arteries: surgical treatment. Texas Heart Inst J 1987;14:23-30.[Medline]



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