Asian Cardiovasc Thorac Ann 2000;8:256-257
© 2000 Asia Publishing EXchange Pte Ltd
Right Coronary Artery Aneurysm
Ali Telli, MD,
Tahir Ya
di, MD,
Mustafa Çikirikçiolu, MD,
Mehmet Tekdoan, MD1,
Department of Cardiovascular Surgery
Ege University Medical Faculty
 zmir, Turkey
1  ifa Medical Center
zmir, Turkey
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For reprint information contact: Ali Telli, MD Tel: 90 232 388 2866 Fax: 90 232 339 0002 Department of Cardiovascular Surgery, Ege University Medical Faculty, Bornova, zmir 35100, Turkey
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Abstract
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A 66-year-old man with an aneurysm of the right coronary artery and stenotic coronary artery disease was successfully treated by lateral aneurysmorrhaphy and coronary artery bypass grafting.
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Introduction
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Coronary artery aneurysm is defined as a dilatation that exceeds 1.5 times the diameter of the patient's largest coronary vessel or adjacent normal segments.1 Early reports of coronary artery aneurysm were based on post-mortem studies. In 1971, Ebert and colleagues2 performed the first successful surgical repair of a coronary artery aneurysm. We report a case of right coronary artery aneurysm with coexisting stenotic coronary artery disease, which was treated by a direct approach to the aneurysm and coronary artery bypass grafting.
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Case Report
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A 66-year-old man was admitted with a history of angina pectoris for 3 years. Coronary angiography demonstrated a saccular aneurysm involving the proximal right coronary artery (Figure 1
). The proximal left anterior descending artery was 75% occluded, the diagonal branches were 90% occluded at their origins, and the proximal circumflex artery was totally occluded. Surgical revascularization and repair of the aneurysm was undertaken. A saccular right coronary artery aneurysm (1.5 to 2 cm) was found (Figure 2). Standard cardiopulmonary bypass was instituted and cold blood cardioplegia was delivered through the coronary sinus to minimize the possibility of distal embolization from the aneurysm. After aortic crossclamping, the right coronary artery aneurysm was opened. It had a smooth white interior and showed no evidence of thrombus. The wall of the aneurysm was resected and plicated with a 7/0 polypropylene running suture. Saphenous vein bypass grafting was performed with distal anastomoses to the first obtuse marginal, first diagonal, and posterolateral branch of the right coronary artery. The left internal mammary artery was anastomosed to the left anterior descending artery. After removing the crossclamp, proximal anastomoses to the aorta were constructed. The patient was weaned from cardio-pulmonary bypass without difficulty. He made a rapid and uneventful recovery and was discharged on the 6th postoperative day. He was well and in Canadian Cardio-vascular Society angina class I at follow-up 6 months postoperatively.
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Figure 1. Coronary angiography demonstrated a saccular aneurysm involving the proximal right coronary artery.
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Discussion
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Increased recognition of coronary artery aneurysm pa-rallels the widespread use of selective coronary angio-graphy. In patients with coronary artery disease, the incidence of coronary artery aneurysm ranges from 1.5% to 4.9%.3 Such aneurysms are most often found in the proximal and mid portions of the right coronary artery, and rarely involve the left main coronary artery.4 The pathogenesis of coronary artery aneurysms is most likely related to injury of the intima and media, causing dilatation of the vessel and intimal ulceration.5 Hemodynamic changes causing alternating high and low pressures over a prolonged period are capable of inducing structural failure of the vessel wall.6
Aneurysms with an internal diameter greater than 8 mm have the worst prognosis and greatest chance of developing coronary thrombosis, rupture, stenosis, or myocardial infarction.7 It has been noted that surgical treatment of combined stenotic and aneurysmal disease was indicated not by the aneurysm but by the presence of coronary obstruction.5 Saccular aneurysms frequently become thrombosed, ruptured, or enlarged, resulting in myocardial infarction, hemopericardium, or death, therefore, repair is recommended.8 Distal bypass with isolation and ligation has been advocated as the ideal surgical approach for thrombosed aneurysms with significant coronary stenosis.8 However, the optimal surgical treatment remains to be elucidated; standard surgical techniques have not been developed due to the limited number of patients.
Retrograde coronary sinus cardioplegia may be used effectively and safely to provide adequate myocardial protection without risking distal embolization from an aneurysm during injection of cardioplegic solution. However, in this case, there was no trace of thrombus within the aneurysm and the aneurysmal wall was not firm. Because of the predisposition to thrombosis and the fear of distal embolization, surgical intervention seems to be the best treatment for saccular right coronary artery aneurysm. Lateral aneurysmorrhaphy combined with distal bypass grafting could be performed without difficulty in this patient. Increased used of standard coronary angio-graphy in patients with an aortic or peripheral arterial aneurysm may increase the rate of diagnosis of coronary artery aneurysm.
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References
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Robertson T, Fisher L. Prognostic significance of coronary artery aneurysm and ectasia in the Coronary Artery Surgery Study (CASS) registry. Prog Clin Biol Res 1987;250:325–39.[Medline]
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Ebert PA, Peter RH, Gunnells JC, Sabiston DC. Resecting and grafting of coronary artery aneurysm. Circulation 1971; 43:593–8.[Abstract/Free Full Text]
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Abstract
Introduction
