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J Thorac Cardiovasc Surg 2003;126:888-890
© 2003 The American Association for Thoracic Surgery

Brief communications

Giant atherosclerotic aneurysm of the left anterior descending artery

Nawwar Al Attar, FRCS, FETCSa, Jean-Louis Sablayrolles, MDb, Patrick Nataf, MD*,a

a Department of Cardiac Surgery, Centre Cardiologique du Nord, St Denis, France
b Department of Radiology, Centre Cardiologique du Nord, St Denis, France

Received for publication March 6, 2003; accepted for publication March 12, 2003.

* Address for reprints: Patrick Nataf, MD, Department of Cardiac Surgery, Centre Cardiologique du Nord, 32–36 rue des Moulins Gémeaux, 93200, St Denis, France
natafp{at}wanadoo.fr

Large coronary aneurysms are mostly due to Kawasaki’s disease. We report a case of giant atherosclerotic aneurysm of the left anterior descending artery (LAD) discovered incidentally in a patient with no previous coronary history. Multislice computed tomography (CT) scan of the heart gave excellent iconography, allowing accurate diagnosis and differentiating it from an aneurysm of the pulmonary artery.

Case history

A 67-year-old man of Algerian descent with no significant medical history presented with sudden onset ataxia and vertigo. The patient was overweight, afebrile, and ataxic. Blood pressure was 140/85 mm Hg and heart rate was regular. Brain CT scan showed left cerebellar infarction. As part of his workup, a posteroanterior chest radiograph showed a voluminous left hilar mass (Figure 1).



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  		Figure 1. Chest radiograph showing left hilar mass.

 
Thoracic CT angioscan (GE Lightspeed16, GE Medical Systems, Chicago. Ill) demonstrated aneurysm of the proximal LAD of 60 mm diameter, in close proximity to the pulmonary artery (Figure 2, A). The patient was otherwise totally asymptomatic and his electrocardiogram was normal. Echocardiography confirmed the presence of an oval mass adjacent to the pulmonary artery. There were no signs of endocarditis. Coronary angiography (Figure 2, B) showed the large proximal LAD aneurysm and significant stenoses of the LAD, with diagonal and circumflex arteries. Doppler imaging demonstrated occlusion of the left internal carotid artery. Leukocyte count was normal, as were markers of inflammatory syndrome. Antiphospholipid antibodies were not detected. Serology for Lyme disease, syphilis, AIDS, and hepatitis B and C were all negative. Biopsy of the temporal artery showed no signs of polyarteritis.



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  		Figure 2. A, Multislice CT scan of the heart (view from above). The aneurysm is clearly shown originating from the LAD. It is composed of a large thrombus surrounding a patent inner channel. Inset is virtual endoscopy of the LAD and aneurysm. B, Coronary angiography of left coronary artery demonstrating the circulating channel of the LAD aneurysm.

 
The patient was operated on 2 months after his stroke under cardiopulmonary bypass for excision of the aneurysm, which contained a large thrombus (Figure 3 and insert) plus grafting of the LAD and diagonal and marginal arteries. The excised portion of the LAD was replaced by a saphenous graft.



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  		Figure 3. Operative view of the giant LAD aneurysm. Inset showed large thrombus in sectioned aneurysm.

 
The patient left the surgical ward after 7 days with persistent minor ataxia. Culture of the excised aneurysm gave no growth, and histopathologic examination showed atherosclerotic changes and absence of inflammatory infiltrate in the arterial wall.

Discussion

Giant coronary artery aneurysms are rare. The most common cause is Kawasaki’s disease within its classical geographic location.1,2 Although atherosclerosis is the responsible pathology in this patient, it characteristically produces small aneurysms and is associated with risk factors for coronary atherosclerosis.

Most patients are asymptomatic, but manifestations of myocar-dial ischemia may occur. Other complications include rupture, thromboembolic phenomenon, and more rarely fistulation into one of the cardiac chambers.3 Indeed, it was the cerebellar stroke that heralded the signs of atherosclerosis in our patient. Although coronary angiography is the gold standard diagnostic examination, multislice CT scan established this diagnosis and was able to differentiate the coronary aneurysm from an aneurysm of the pulmonary artery by "peeling" it from adjacent structures. With virtual endoscopy the cavity of the aneurysm was explored and shown to be occupied by a large thrombus (Figure 2, A insert).

The left coronary trunk is a rare localization with little more than 30 cases described in the literature. To avoid rupture of the aneurysm, resection and replacement of the aneurysmal LAD with venous graft between the cut ends associated with triple bypass of the LAD and diagonal and marginal arteries with the mammary arteries crafted in a Y graft was undertaken. The size and site of the described aneurysm make it quite exceptional; furthermore, we believe that it is one of the largest atherosclerotic aneurysms reported in the medical literature.4,5

References

  1. Koizumi J, Izumoto H, Ohsawa A, Ishibashi K, Ishihara K, Kawazoe K. Giant coronary artery aneurysm in diagonal artery; report of a case. Kyobu Geka. 2002;55:793–795[Medline]
  2. Nakamura Y, Yashiro M, Oki I, Tanihara S, Ojima T, Yanagawa H. Giant coronary aneurysms due to Kawasaki disease: a case-control study. Pediatr Int. 2002;44:254–258[Medline]
  3. Shrivastava V, Akowuah E, Cooper GJ. Coronary artery aneurysm with a fistulous connection to the right atrium mimicking a sinus of Valsalva aneurysm. Heart. 2003;89:E4[Medline]
  4. Merchan A, Lopez-Minguez JR, Alonso F, Fernandez De La Concha J, Gonzalez R, Martinez De La Concha L. Giant left main coronary aneurysm without associated coronary lesions. Rev Esp Cardiol. 2002;55:308–311[Medline]
  5. Barettella MB, Bott-Silverman C. Coronary artery aneurysm: an unusual case report and a review of the literature. Cathet Cardiovasc Diagn. 1993;29:57–61[Medline]



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