Repair of a Giant Right Coronary Artery Aneurysm

Coronary artery aneurysm (CAA) is quite uncommon, occurring in less than 5 percent of angiography series. It is defined as the dilatation of a coronary artery which exceeds 50 percent of the reference vessel diameter (1). A CAA is termed giant if its diameter exceeds the reference vessel diameter by more than four times or if it is more than 8 mm in diameter (2). Giant CAAs are extremely rare, and their incidence is reported to be around 0.02 percent (3).

Despite the fact that etiology of CAAs is heterogeneous, the underlying mechanism remains vessel wall weakening and subsequent dilatation (3). Multiple factors have been incriminated for CAA formation, but atherosclerosis in adults and Kawasaki disease in children are responsible for the vast majority of CAAs (3). The right coronary artery (RCA) is most commonly affected, followed by the left circumflex (LCX) artery and the left anterior descending (LAD) artery.

The prognosis of CAAs depends mainly on the size of the aneurysm. In general, giant CAAs have a high risk of morbidity and mortality. According to some authors, approximately half of giant aneurysms become obstructed, leading to MI, arrhythmia, or sudden death (4).

Compared with small aneurysms, which often have a favorable prognosis and a low risk of cardiovascular events and mortality, giant aneurysms may be complicated by ischemia, myocardial infarction, distal embolization due to thrombus formation within the aneurysm, calcification, fistula formation, and spontaneous rupture (5).

There are no distinctive clinical features of CAAs, but chest pain in patients with coronary aneurysms suggestive of stable angina is the most common symptom.

Surgical exclusion for CAAs is considered the mainstay of treatment, especially in patients with objective evidence of ischemia and in cases with rapid increase in dimension over time.



The Patient

This video presents the case of a seventy-nine-year-old man who underwent successful repair of a giant coronary artery aneurysm and CABG. The patient presented after an episode of loss of consciousness. The physical examination was unremarkable. There were no ECG changes, and echocardiography showed a mildly reduced ejection fraction of 50 percent. A subsequent workup with thorax CT and angiography revealed a giant right coronary aneurysm measuring 5.2 x 5.7 cm with signs of thrombosis and calcification in the aneurysmal sac.

The Surgery

The patient was scheduled for an operation. Following median sternotomy and administration of heparin, the ascending aorta and right atrium were cannulated.

The aorta was then cross-clamped, and cold blood cardioplegia solution was delivered in the aortic root. Once the heart was arrested, surgeons started careful dissection around the borders of the aneurysm. The proximal and distal RCA were identified and ligated. Blunt finger dissection was utilized to free the base of the aneurysm, which was adhered to the right atrium and ventricle. This was very helpful in terms of separation of the tissues and formation of a safe plane.

Once the aneurysm was excised, a bypass to the distal RCA was performed with a vein graft. After careful hemostasis, the patient was weaned off cardiopulmonary bypass with minimal support and was extubated a few hours later.

References

1. Eshtehardi P, Cook S, Moarof I, Triller HJ, Windecker S. Giant coronary artery aneurysm: imaging findings before and after treatment with a polytetrafluoroethylene-covered stent. Circ Cardiovasc Interv. 2008 Aug;1(1):85-6. doi: 10.1161/CIRCINTERVENTIONS.107.763656
2. Kato H, Sugimura T, Akagi T, Sato N, Hashino K, Maeno Y, Kazue T, Eto G, Yamakawa R. Long-term consequences of Kawasaki disease: a 10- to 21-year follow-up study of 594 patients. Circulation. 1996; 94: 1379–1385
3. Arcinas LA, Yan W, Jassal DS, Love MP, Yamashita MH, Elbarouni B. Multimodality imaging of a giant right coronary artery aneurysm. Can J Cardiol. 2018;34(12):1688.e5-1688 e7.
4. Peng Y, Li Y, Jiang Y. Rare case of a giant thrombosed left anterior descending coronary artery aneurysm. J Cardiothorac Surg. 2020 Jul 30;15(1):204. doi: 10.1186/s13019-020-01250-8.
5. Indolfi C, Achille F, Tagliamonte G, Spaccarotella C, Mongiardo A, Ferraro A. Polytetrafluoroethylene stent deployment for a left anterior descending coronary aneurysm complicated by late acute anterior myocardial infarction. Circulation. 2005; 112: e70–e71

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