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J Thorac Cardiovasc Surg 2001;122:626-627
© 2001 The American Association for Thoracic Surgery
Brief Communications |
lhan Gölba
i, MDa
ahin, MDbFrom the Departments of Cardiac Surgery,a Anesthesiology,b and Cardiology,c Akdeniz University School of Medicine, Antalya, Turkey.
Received for publication Jan 12, 2001. Accepted for publication Jan 24, 2001. Address for reprints: Cengiz Türkay, MD, Akdeniz Üniversitesi Tip Fakültesi, Kalp-Damar Cerrahisi Anabilim Dali, 07070, Antalya, Turkey (E-mail: Turkay{at}med.akdeniz.edu.tr).
Coronary artery aneurysms are noted in 0.15% to 4.9% of patients undergoing coronary angiography.
1 They rarely involve the left main coronary artery (LMCA). According to Lenihan and coworkers, 2 coronary artery aneurysms in patients younger than 33 years old are congenital. In most patients older than 33 years and in all patients older than 56 years, coronary artery aneurysms are caused by atherosclerosis. 2 Both true and false aneurysms may rupture or embolize. Various surgical strategies, such as isolation, resection, reconstruction, and ligation, have been devised to prevent these complications. 3
We report a case of successful ligation of an aneurysm of the LMCA and simultaneous 4 coronary artery bypass procedures. The postoperative course was uneventful.
Clinical summary
A 59-year-old man with a history of angina pectoris for 1 month was admitted to the hospital because of progressive increase in anginal symptoms. He had been treated for hypertension for 8 years.
Results of physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm. The chest radiograph and M-mode echocardiograms showed no abnormalities.
Coronary angiography demonstrated an aneurysm of the LMCA and significant stenoses in the high lateral branch of the circumflex coronary artery and proximal right coronary artery. There was no evidence suggestive of thrombus or dissection. The aneurysm was calculated to be 12 mm in diameter(Figure 1). Results of left ventricular cineangiography were within normal limits.
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Discussion
Multiple coronary artery aneurysms in childhood and adolescence are usually late complications of Kawasaki disease. Angiography, transesophageal echocardiography, and magnetic resonance imaging can be used for the diagnosis and follow-up of such aneurysms. If there is no history of predisposing risk factors such as polyarteritis nodosa, neurofibromatosis, or syphilis, the cause of coronary artery aneurysms is frequently congenital. 3 In atherosclerosis, the destruction of the medial layer gradually leads to dilatation.
The natural course of atherosclerotic coronary artery aneurysms is variable. The main complication is myocardial ischemia or infarction, 1,4 but aneurysm rupture can also occur rarely. 5 Rath, Har-Zahav, and Battler 6 reported that occlusion of the aneurysmal nonstenotic coronary artery caused infarction in all 5 of their patients on follow-up. Conservative treatment consists in attempts to prevent thromboembolic complications by anticoagulants or antiplatelet drugs. 3 Because of the rarity of LMCA aneurysms, it is difficult to standardize treatment. In early cases, LMCA aneurysms were treated by bypass grafting alone without exclusion of the aneurysm from the coronary circulation; later, they were treated by isolating the coronary artery aneurysm with ligatures or resecting the aneurysm and simultaneously performing the necessary bypass grafts. 2,7-9 We think that ligation or resection of the aneurysm is necessary to avoid complications such as extension, thrombosis, rupture, or coronary arterial embolization.
In some patients, ligation of the aneurysm may be difficult because the aneurysm is located behind the pulmonary artery. The pulmonary artery can easily be divided and repaired, and this greatly facilitates exposure of the LMCA and eliminates any tedious or dangerous dissection posteriorly with traction on the pulmonary artery. 10 If the main pulmonary artery can be satisfactorily mobilized, it need not be divided. In the present case, we were able to visualize the whole LMCA easily and safely, without transecting the main pulmonary artery, because of the proximal location of the LMCA aneurysm.
In summary, the LMCA may be exposed without transecting the main pulmonary artery. Coronary bypass grafting with ligation of the aneurysm is an ideal surgical treatment for aneurysms of the LMCA.
References
This article has been cited by other articles:
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  R. Agarwal, V. Jeevanandam, and N. Jolly Surgical Treatment of a Giant Coronary Artery Aneurysm: A Modified Approach Ann. Thorac. Surg., October 1, 2007; 84(4): 1392 - 1394. [Abstract] [Full Text] [PDF]
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 B. B. Pinheiro, W. V. Fagundes, C. A. Gusmao, A. M. C. Lima, L. H. Santos, and G. B. Vieira Surgical management of a giant left main coronary artery aneurysm J. Thorac. Cardiovasc. Surg., November 1, 2004; 128(5): 751 - 752. [Full Text] [PDF]
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C. A. Anderson, F. Filsoufi, A. Kadner, and D. H. Adams Repair of a left main coronary artery aneurysm using the circumflex femoral artery as a Y-interposition graft Ann. Thorac. Surg., July 1, 2004; 78(1): 314 - 316. [Abstract] [Full Text] [PDF]
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 N. Motoyoshi, T. Komatsu, Y. Moizumi, and K. Tabayashi Spontaneous rupture of coronary artery Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 470 - 471. [Abstract] [Full Text] [PDF]
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