J Thorac Cardiovasc Surg 2002;123:817-820
© 2002 The American Association for Thoracic Surgery
Reverse saphenous interposition vein graft repair of a giant atherosclerotic aneurysm of the left anterior descending coronary artery
Heyman Luckraz, FRCS,
Dinah V. Parums, PhD, FRCPath, FCCP,
John Dunning, FRCS Cambridge, United Kingdom
From Papworth Hospital, Papworth Everard, Cambridge, United Kingdom.
Received for publication Sept 17, 2001. Accepted for publication Oct 23, 2001.
Address for reprints: H. Luckraz, FRCS, Specialist Registrar Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, United Kingdom (E-mail: Heyman.Luckraz{at}paworth-tr.anglox.nhs.uk).
The incidence of coronary artery aneurysm is reported to be around 5%.
1 The involvement of the left anterior descending coronary artery (LAD) varies from 32% 2 to 52%. 3 Several repair techniques have been described and include proximal or distal ligation of the aneurysm, 4 aneurysmal thrombectomy, 5 aneurysmorrhectomy, 6 aneurysmal resection with direct end-to-end anastomosis, 7 intraluminal stenting, 8 coil embolization, 9 and reverse saphenous interposition grafting. 10 We describe our experience in dealing with a giant (>5 cm in diameter) atherosclerotic coronary aneurysm of the LAD using the latter technique.
Clinical summary
A 68-year-old man with an 18-month history of chest pain and shortness of breath (New York Heart Association class II) was referred for coronary artery bypass graft surgery. Risk factors for ischemic heart disease included hypertension, hypercholesterolemia, family history of ischemic heart disease, and smoking. There was no history or clinical evidence of connective tissue disorder or sexually transmitted or inflammatory diseases. Coronary angiography revealed triple-vessel disease with a giant aneurysm of the LAD (Figure 1). These findings were confirmed intraoperatively (Figure 2). The aneurysm was opened, and the contents were marsupialized. There was a septal branch of the LAD just beyond but not within the aneurysmal sac (Figure 1). The 2 normal-sized ends of the LAD were then anastomosed to a short length of autologous reversed long saphenous vein (Figure 3), and the aneurysm sac was closed over this graft. A left internal thoracic artery graft was performed to the mid-LAD because of significant disease beyond the aneurysm (Figure 1). The macroscopic appearance of the aneurysm contents is illustrated in Figure 4. Histopathologic analysis of the diseased vessel revealed an atheromatous collection (Figure 5).
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Fig. 1. Coronary angiography (right anterior oblique view) of the left coronary artery showing aneurysm of the proximal LAD, a mid-LAD stenosis (black arrow), and an intervening septal branch in between.
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Fig. 3. The aneurysmal sac was opened, and an interposition vein graft was sutured at either end of the normal-caliber LAD (black arrows).
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Fig. 5. Microscopic assessment of the aneurysm. A, Photomicrograph of a section of coronary artery shows intimal atherosclerosis (a), attenuated media (b), and adventitial chronic inflammation (c). These are the 3 features of chronic periarteritis. There is no acute inflammation, no fibrinoid change, no dissection, no endarteritis obliterans of vasa vasorum, and no granuloma, and no infectious organisms are seen. (Original magnification 20x, hematoxylin and eosin.) B, Photomicrograph of a section of coronary artery stained for collagen and elastin with elastin van Giesen stain shows intimal atherosclerosis (e), attenuated media (f), and adventitial chronic inflammation (g). The media has been replaced by mononuclear cells and collagen, with no remaining elastin fibers. (Original magnification 20x, elastin van Giesen stain.) C, High-power photomicrograph of a section of coronary artery atherosclerotic intima. This formalin-fixed, paraffin-embedded section is stained for lipids with oil-red-O. Cholesterol clefts remain where soluble lipid has been dissolved, but red-staining insoluble lipid (ceroid) is seen within the intimal atheroma, within macrophages, and extracellularly. This is the hallmark of advanced atherosclerosis. (Original magnification 60x, oil-red-O on a paraffin section.)
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The patient had an uneventful postoperative recovery and was discharged home on the seventh postoperative day. Four months postoperatively, the patient is mobilizing well and is symptom free.
Comment
Coronary aneurysm was first described, post mortem, by Morgagni 11 in 1761. It is an unusual finding during coronary angiography. 1 Because of this rarity, the natural history and therapeutic implications remain undefined.
An aneurysm is defined as a localized dilatation of a major vessel that exceeds 1.5 times the expected diameter of that section compared with the normal segments above and below. 12 The most common cause is atherosclerosis. Other causes are congenital malformations (connective tissue disorders) and inflammatory (arteritis and Kawasaki disease), iatrogenic (trauma and postangioplasty), and infectious (mycotic aneurysms) conditions. 12 Histopathologic findings include underlying destruction of the media, which becomes thinned. The latter, in association with an increase in wall stress, becomes aneurysmal. 12 Indications for surgical intervention include rupture, 4 vessel occlusion, thrombosis, and embolization. 2 Because of its rarity, no surgical consensus has yet been drawn concerning the most appropriate surgical management of this lesion.
Aneurysmectomy with direct end-to-end anastomosis has previously been described by Westaby and associates. 7 This was not possible in this case because of the large size of the aneurysm. End-to-end anastomosis is not ideal because the suture line is always under the threat of being under tension, especially when the empty heart resumes its normal size and shape after cessation of cardiopulmonary bypass. The suture line can therefore be weakened and has the potential of becoming aneurysmal.
Nonsurgical intervention with a percutaneous intraluminal stent insertion is an alternative. However, because the patient was already undergoing coronary artery bypass grafting, it was more logical to deal with the aneurysm at this point in time. Furthermore, stents are at risk of thrombosis and vessel wall damage, requiring further interventions.
Surgical repair with an interposition graft restores blood flow, which would otherwise be compromised when the proximal or distal ligation technique is used. Although this technique was previously described by Firstenberg and colleagues, 10 we performed this type of repair completely unaware of its previous description. In this case it enabled reperfusion of septal vessels, thus avoiding significant myocardial ischemic injury.
Conclusion
Coronary artery aneurysms can be safely managed with a reverse interposition vein graft. This provides continuous blood flow throughout the entire distribution of the coronary artery tree and reduces the insults of myocardial ischemia.
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