Asian Cardiovasc Thorac Ann 2002;10:55-57
© 2002 Asia Publishing EXchange Pte Ltd
Multiple Giant Aneurysms of Coronary Arteries
Gulshan K Sethi, MD,
Sivaprasad Mullangi, MD,
Steve Goldman, MD1
Department of Cardiovascular and Thoracic Surgery
1 Division of Cardiology Southern Arizona VA Healthcare System and University of Arizona College of Medicine Tucson, Arizona, USA
|
|
Gulshan K Sethi, MD Tel: 1 520 626 6339 Fax: 1 520 626 4042 email: sethi{at}u.arizona.edu
Department of Cardiovascular and Thoracic Surgery, University of Arizona Sarver Heart Center, 1501 N. Campbell Avenue, Room 4402, Tucson AZ 85724-5071, USA.
|
 |
ABSTRACT
|
|---|
Multiple giant aneurysms of the coronary arteries occur extremely rarely and are usually associated with Kawasaki disease in children. A 53-year-old man with multiple giant coronary artery aneurysms was treated successfully by aortocoronary bypass grafting.
|
INTRODUCTION
|
|---|
Giant aneurysms of the coronary arteries are extremely rare. They are usually reported in children with Kawasaki disease. A case of multiple giant aneurysms of the proximal coronary arteries in an adult is described.
|
CASE REPORT
|
|---|
A 53-year-old Hawaiian man of Japanese descent was admitted with accelerating angina pectoris. He had a positive dipyridamole thallium test consistent with ischemia involving the left anterior descending and right coronary artery regions. A coronary arteriogram revealed multiple large aneurysms of the proximal coronary arteries, ranging in size from 1 to 4 cm, and proximal stenoses of all 3 vessels (Figures 1 and 2
). There was no evidence of thrombi within the aneurysms, and the distal vessels were free of disease. Left ventricular function was normal. Myocardial revascularization was undertaken using a left internal thoracic artery graft to the left anterior descending coronary artery, and reversed saphenous vein grafts to the first obtuse marginal branch of the circumflex artery and the right coronary artery. At surgery, aneurysms were palpable in the right coronary and left anterior descending artery. The distal vessels were normal and there was no visible evidence of coronary atherosclerosis. The postoperative course was uneventful. The patient was initially anticoagulated with warfarin and subsequently maintained on long-term antiplatelet therapy. He was asymptomatic at the 3-year follow-up.
View larger version (158K):
[in this window]
[in a new window]
|
Figure 1. Coronary angiogram showing a giant aneurysm of the proximal right coronary artery. The distal vessel appears to be free of significant disease.
|
|
View larger version (124K):
[in this window]
[in a new window]
|
Figure 2. Left coronary arteriogram showing multiple giant aneurysms of the left main coronary artery, the proximal circumflex artery, and the left anterior descending coronary artery.
|
|
|
DISCUSSION
|
|---|
Aneurysms of the coronary arteries are extremely rare. Approximately 20% are congenital, and the rest are acquired.1,2 The etiology of acquired aneurysms includes atherosclerosis, infection, and inflammation. Occasionally, such aneurysms may be associated with percutaneous transluminal coronary angioplasty or directional atherectomy of the coronary arteries. The cause of a coronary aneurysm can usually be deduced from the clinical course and appearance of the lesion.1 Congenital aneurysms mainly affect younger patients; they are large and involve only one vessel (most often the right coronary artery). Aneurysms due to atherosclerosis are small and associated with stenotic lesions of the coronary arteries; risk factors for coronary atherosclerosis may be present. Aneurysms of bacterial origin are small and solitary, the other coronary arteries are free of disease, and there is always a history of septicemia. Aneurysms resulting from inflammatory processes are usually seen in children and can be due to periarteritis nodosa or mucocutaneous lymph node syndrome (Kawasaki disease). This patient was unusual because although it could not be definitely established, it is believed he developed coronary artery aneurysms due to Kawasaki vasculitis in childhood, and was fortunate not to have any complications until recently. This assumption is based on the presence of multiple giant aneurysms of the proximal coronary arteries, normal distal vessels, and the exclusion of other causes of coronary artery aneurysms.
Kawasaki disease is a multisystem disorder of unknown etiology. It is the most common cause of ischemic heart disease in children.3 The highest prevalence is found in Japan, and Asian children are seven times more susceptible to Kawasaki disease than Caucasian or Hispanic children.4 Approximately 1.4% of patients with Kawasaki disease develop coronary artery aneurysms, and 0.5% to 2% of them die as a result of myocardial infarction due to thrombotic occlusion of the coronary arteries, or rarely, because of aneurysmal rupture.3–5 Two-dimensional echocardiography is the standard mode of diagnosis of coronary artery aneurysms in children. However, it is less reliable in older patients as a larger body size makes visualization of coronary aneurysms by 2-dimensional echocardiography difficult. Occasionally, the aneurysms may become scarred and calcified. Coronary arteriography is recommended in all patients undergoing surgery.
Recently, an increasing number of adult patients with myocardial infarction due to obstructed large coronary artery aneurysms, reminiscent of Kawasaki syndrome, have been described. These patients usually have relatively few risk factors for atherosclerosis, and their distal coronary arteries are normal.5 Our patient also had no known risk factor for coronary artery disease and his distal vessels were free of atherosclerosis. The develop-ment of coronary artery aneurysms can be significantly reduced with early use of intravenous gamma globulin during acute Kawasaki syndrome.4 Subsequently, patients should be treated with aspirin and/or warfarin, with regular follow-up by 2-dimensional echocardiography. The prognosis worsens rapidly when myocardial infarction occurs. Kato and colleagues6 reported a mortality rate of 22% after the first infarct, 66% after a second infarct, and 87% after a third infarct. Thus, myocardial revascu-larization is important in preventing premature death and improving the quality of life.5 Occasionally, recurrent myocardial infarction may produce severe left ventricular dysfunction and, in such instances, heart transplantation may be the only viable option to treat these patients.
Fortunately, as such coronary artery aneurysms and stenoses occur in the proximal segments of the major coronary arteries, they are amenable to coronary artery bypass grafting. Arterial conduits are preferred over vein grafts because of their proven long-term patency. Recently, in a multicenter study of 168 patients with Kawasaki disease who underwent coronary bypass grafting, Kitamura and colleagues7 reported that patients with internal thoracic artery grafts had a significantly higher actuarial survival rate (98.7% at 90 months) compared to those who received saphenous vein grafts alone (81.6%). Techniques for managing coronary artery aneurysms include aortocoronary bypass grafting with or without ligation of the coronary artery proximally and distally to the aneurysm, resection of the aneurysm with bypass grafting to the distal vessel, or placement of interposition grafts as described by Firstenberg and colleagues.8 In this case, the coronary arteries were bypassed without ligating the vessels because of the anatomic location of the aneurysms and the absence of thrombi. Extra dissection to ligate the vessels proximal and distal to the aneurysm was avoided in view of the potential danger in sacrificing some of the major coronary branches.
|
REFERENCES
|
|---|
-
Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary arteries: report of ten cases and review of the literature. Am J Cardiol
1963;11:228–37.[Medline]
-
Letac B, Cazor JL, Cribier A, Sibille C, Toussaint C. Large multiple coronary artery aneurysms in adult patients: a report on three patients and a review of the literature. Am Heart J
1980;99:694–700.[Medline]
-
Pennington DG, Williams V. Anomalies of the coronary vessels. In: Baue AK, Geha AS, Hammond GL, Laks H, Naunheim K, editors. Glenn's thoracic and cardiovascular surgery. Stanford, Connecticut: Appleton & Lange, 1996:1521–31.
-
Takahashi M. Management of giant coronary aneurysms due to Kawasaki syndrome. ACC Curr J Rev
1996;74–6.
-
Kato H, Sugimura T, Akagi T, Sato N, Hashino K, Maeno Y, et al. Long-term consequences of Kawasaki disease. A 10- to 21-year follow-up study of 594 patients. Circulation
1996;94:1379–85.[Abstract/Free Full Text]
-
Kato H, Ichinose E, Kawasaki T. Myocardial infarction in Kawasaki disease: clinical analyses of 195 cases. J Pediatr
1986;108:923–7.[Medline]
-
Kitamura S, Kameda Y, Seki T, Kawachi K, Endo M, Takeuchi Y, et al. Long-term outcome of myocardial revascularization in patients with Kawasaki coronary artery disease. A multicenter cooperative study. J Thorac Cardiovasc Surg
1994;107:663–74.[Abstract/Free Full Text]
-
Firstenberg MS, Azoury F, Lytle BW, Thomas JD. Interposition vein graft for giant coronary aneurysm repair. Ann Thorac Surg
2000;70:1397–8.[Abstract/Free Full Text]
TOP
ABSTRACT
INTRODUCTION
