Successful surgical treatment of giant coronary artery aneurysm with fistula

Late Coronary Aneurysm Formation after Kawasaki Disease: a Review of Mechanistic and Clinical Aspects

Evolution of coronary artery aneurysms (CAAs) has been an ominous clinical finding in patients with Kawasaki disease (KD). CAAs generally emerge within the first few weeks in patients with KD, and appear to be strongly associated with the failure to timely initiate specific management strategies. CAA formation might occasionally arise as a late-onset phenomenon long after the index KD episode. Late CAAs in the setting of KD have particular mechanistic and clinical characteristics. Late CAAs in the setting of KD may be confused with other CAA types (atherosclerotic, etc.), and are possibly underdiagnosed in clinical practice.

In patients with Kawasaki disease (KD), evolution of coronary artery aneurysms (CAAs) generally emerges within the first few weeks after disease onset. However, CAA formation in these patients might occasionally arise as a late-onset phenomenon after a long latent period. Characteristically, late CAAs manifest as new-onset vascular pathologies or expansion of long-stable CAAs on coronary imaging modalities, and might have diverse mechanistic and clinical implications. Accordingly, the present paper aims to focus on late CAA formation and its implications in the setting of KD.

Huge Coronary Aneurysm in a Morbidly Obese Man with Exertional Dyspnea and Chest Pain

Patient: Male, 64-year-old

Final Diagnosis: Huge coronary aneurysm

Symptoms: Chest discomfort • dyspnea

Medication: Losar 25 mg twice daily • Amlodipine 5 mg twice daily • Aspirin 80 mg daily • Atorovastatin 20 mg daily • Pantaprazole 20 mg daily

Clinical Procedure: Coronary artery bypass graft surgery

Specialty: Cardiac Surgery • Cardiology

Colossal left main to right atrium fistula ligation complicated by left circumflex STEMI

Congenital left main (LM) coronary artery to right atrium fistulas with progression to aneurysm development are rare. Most patients remain asymptomatic, but for those with progressive symptoms, intervention is required. However, there are potential life-threatening complications associated with surgical intervention. We present a case of an extremely rare markedly aneurysmal LM to right atrial fistula treated with surgical ligation complicated by inferolateral ST-elevation myocardial infarction several days post-operatively treated successfully using mechanical aspiration thrombectomy, a stent-retriever, balloon angioplasty, and subsequent intravascular ultrasound-guided percutaneous coronary intervention with drug-eluting stent.

Rare case of a giant thrombosed left anterior descending coronary artery aneurysm

Background

Coronary artery aneurysms (CAAs) are rare, and giant CAAs are even rarer. The pathophysiology of this phenomenon is still unknown.

Case presentation

Herein, we present the case of a 49-year-old male with a giant aneurysm in the left anterior descending artery.

Conclusions

The optimal treatment for CAAs is debatable, but surgical intervention is preferred for giant CAAs.

Successful sparing approach between the ascending aorta and the main pulmonary artery to the giant coronary aneurysm of the left main coronary artery

Coronary aneurysm located just above the left main coronary artery (LMT) is rare and difficult to treat. How the aneurysm is accessed is very important as it determines the result of the surgery. A 70-year-old man with a large coronary aneurysm (40 mm in diameter) in the LMT underwent surgery to prevent its rupture; however, there was severe adhesion. Initially, dissection of the ascending aorta or the pulmonary artery seemed necessary to access the aneurysm; however, the process was possible with limited dissection between the ascending aorta and the pulmonary artery, and we succeeded in firmly closing the LMT site of entry.

An unknown mass on the cardiac surface with huge coronary aneurysm and fistula: A case report

Cardiac mass is rare in the clinic and can be primary or secondary. It is quite rare to find a mass only on the cardiac surface. Today we report a patient with a cardiac mass grown on the cardiac surface and also had a coronary aneurysm combined a coronary fistula, pathology examination showed that the mass was not a tumor but an aneurysm with thrombosis. This is the first time that a primary thrombus discovered on the surface of the heart.

Giant right coronary artery aneurysm. Case Report

Introduction: Coronary aneurysms are rare and are linked to drug abuse; symptomatology depends on the coronary anatomy. This is a case of acute coronary syndrome associated with a giant right coronary aneurysm.Case description: A 40-year-old male, with history of heroin and crack use since age 20, attended consultation due to dyspnea, stable angina and diaphoresis. An electrocardiogram showed ST segment overlay on the underside and troponin problems. A coronary catheterization was performed, which revealed apparent inconclusive aortato-right atrium fistula. Based on the findings, angiotomography and magnetic resonance imaging were performed, finding a giant right coronary aneurysm. The aneurysm was resected using extracorporeal circuit, femoral cannulation, moderate hypothermia, aortic cross-clamping and cardioplegia, and the right coronary artery was revascularized with the left internal saphenous vein. The patient had a satisfactory postoperative period and was discharged after 7 days.Conclusion: There is an important association between drug use and the development of coronary aneurysms. Aneurysm size makes diagnosis difficult, so complementary studies are necessary to establish a differential diagnosis. An appropriate surgical approach allows for a complete resection of the aneurysm and optimal coronary revascularization.

Coronary Aneurysm: An Enigma Wrapped in a Mystery

Coronary aneurysms are defined as localized dilatations of the coronary arteries. In this review, we will analyze the most important aspects of this rare condition while trying to provide answers to the following questions: What is a coronary aneurysm? What causes coronary aneurysm? Do coronary aneurysms cause symptoms? Can coronary aneurysms rupture? How do we treat coronary aneurysms?

A case of ruptured infective coronary artery aneurysm

Infective coronary artery aneurysm is extremely rare and ruptured aneurysm is life-threatening. We report a case of ruptured coronary artery aneurysm, which was successfully treated by the patch closure technique and coronary artery bypass grafting. Pathological examination revealed purulent inflammation in the aneurysmal wall. Prompt diagnosis and appropriate treatment were essential.

Giant atrial septal aneurysm originating from the right coronary artery

Giant coronary artery aneurysm is a rare clinical entity and its involvement in the interatrial space is extremely rare. We here report the rare surgical case of a 67-year old man with giant right coronary artery aneurysm located in the atrial septum with fistula formation to the right atrium, complicated with congestive heart failure, rapid atrial fibrillation and left atrial appendage thrombus. The patient eventually recovered fully without sequelae.

Multiple giant coronary artery aneurysms: a case report

BACKGROUND

Coronary artery aneurysm is defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. Giant aneurysms are those aneurysms that measure greater than 2cm in diameter. There have been many pathologic diseases, including atherosclerosis, that have been implicated in the development of coronary artery aneurysms.

MATERIALS AND METHODS

We report a case of a 61-year-old African American male with multiple comorbidities including hypertension, congestive heart failure, abdominal aortic aneurysm, and bilateral iliac aneurysms, who was admitted to our hospital with exacerbation of congestive heart failure. Less than 2weeks after admission, the patient suffered cardiac arrest while receiving dialysis and was unresponsive to resuscitative measures.

FINDINGS

Autopsy was performed and revealed significant cardiomyopathy and giant coronary artery aneurysms involving the left anterior descending, left circumflex, and right coronary arteries. Both ventricles showed hypertrophy and dilation with multifocal areas of chronic myocardial scarring.

CONCLUSIONS

Coronary artery aneurysms and giant coronary artery aneurysms are an uncommon. As there are few reported cases in the literature, the cause, detection, and treatment of this disease are still largely unknown.

Case Report: A Rare Case of a Giant Right Coronary Artery Aneurysm

We report the case of a 34-year-old female patient with a giant thrombus-filled aneurysm of the right coronary artery presenting as a spherical cardiac mass on echocardiography. The cardiac mass was found to be an 8-cm right coronary artery aneurysm on cardiac magnetic resonance imaging, which also revealed a 3.5-cm proximal left coronary aneurysm and a very small aneurysm at the origin of the obtuse marginal coronary artery. Due to the extent and size of the right coronary aneurysm, a decision for surgical intervention was made. Resection of the right coronary artery aneurysm with vein graft replacement and a bypass to the left anterior descending followed by subsequent exclusion of the aneurysm was successfully performed.

A giant coronary artery aneurysm with a fistula followed-up for 12 years using the contrast-enhanced computed tomography scan

We report a case of a 35-year-old woman who was diagnosed with a giant coronary artery aneurysm (CAA) with a fistula and followed-up using the contrast-enhanced computed tomography scan and 2-dimensional transthoracic echocardiography. The diameter and volume cubic content of the giant CAA had increased linearly during the 12-year follow-up period without any complications. As there are few reports about long-term follow-up of giant CAAs without a surgical intervention, the natural course of a giant CAA is still unclear. Thus, we may need to closely follow-up chronological changes of a giant CAA to decide the treatment strategy.

Transcatheter closure of coronary artery fistula using Guglielmi detachable coil

Background

Coronary artery fistula (CAF) is a rare anomaly. Transcatheter CAF closure has been introduced using various materials, but only few data are available on the Guglielmi detachable coil (GDC). The advantage of using GDC for transcatheter CAF closure is more controllable, therefore much safer when compared to other coils. This report is about our experience in transcatheter closure of CAF using fibered GDC in our hospital.

Methods & Results

From 2002 to 2007, there were 10 patients with CAFs (age range: 28 to 56 year-old, 7 males) who underwent transcatheter CAF closure. There were a total of 19 CAFs which originated from right coronary (n = 5), left circumflex (n = 3), left anterior descending artery (n = 10) and left main trunk (n = 1). Median number of coil deployment for each fistula was 3 (range: 1 to 6). The pulmonary artery was the most common site of the distal communication of CAFs (n = 14), followed by right atrium (n = 3), left atrium (n = 1) and left ventricle (n = 1). Immediate coronary angiography after GDC deployment revealed no residual shunt in 12 (63.2%) CAFs, significant reduction of the flow in 5 (26.3%), while 2 (10.5%) could not be closed due to small size. Nine (90%) patients underwent a repeated angiography within 3 to 8 months. Among 12 CAFs that were occluded immediately post-deployment, there were 2 CAFs with insignificant residual flow. Among 6 CAFs with significantly decreased flow immediately post-deployment, 2 were occluded totally in the follow-up angiography. In total, 12 (70.5%) CAFs were occluded completely and 5 (29.5%) CAFs still had insignificant residual flow, which did not need any additional coil deployment. During a mean follow up of 4.3 ± 0.7 year, all patients remained symptom and complication free.

Conclusions

The fibered GDC is a safe and effective method for percutaneous closure of the CAFs.

Coronary artery fistula

Although coronary arterial fistula is rare, it is one of the most common among the coronary artery anomalies. Coronary arterial fistula most commonly affects the right side of the heart. It may occur isolated or along with congenital heart diseases. Angiography remains the best investigation for diagnosing the disease. Unless very large and hemodynamically significant, it is usually asymptomatic in younger patients. With increasing age, symptoms begin to appear, and the incidence of complication rises. Treatment by transcatheter or surgical closure gives the best results, provided this is performed early in the course of the disease. This review was prepared by searching the terms "coronary artery fistula," "coronary cameral fistula," "surgical management of coronary arterial fistula," "MDCT in coronary artery fistula," and "multiple coronary artery fistulae" in Google Scholar, PubMed, and PubMed Central and exploring the related articles shown on the side of page.

[Noninvasive imaging techniques to study coronary artery aneurysms]

Given the growing evidence about the use of membrane-covered stents to treat coronary artery aneurysms, it is fundamental to know the exact anatomy of the aneurysm to enable patients to be selected correctly. Invasive heart catheterization has limitations for diagnostic purposes and can underestimate the size of the aneurysm. In this article, we review the noninvasive diagnostic imaging techniques for the study of coronary artery aneurysms, illustrating the usefulness of each technique.

Off-pump surgery for giant right coronary artery aneurysms

Coronary artery aneurysms larger than 5 cm are exceedingly rare, and a standard treatment for them is lacking. We report two cases of giant right coronary artery aneurysms successfully treated by off-pump resection of the aneurysm and bypass grafting. The controversy surrounding the proper management of such cases is discussed.

Sudden Death Due to Ruptured Three-Vessel Giant Coronary Artery Aneurysm in a 28 Year Old Woman with Trisomy 21

We report a case of sudden death due to rupture of a giant right coronary artery aneurysm, likely a sequela of remote Kawasaki disease, in a young woman with Down syndrome. The decedent was a 28 year old female with trisomy 21 who was found deceased in the backyard pool. An autopsy disclosed an enlarged heart with 400 ml of clotted blood in the pericardial sac and undiagnosed giant coronary artery aneurysms involving the left anterior descending, left circumflex, and right coronary artery, with rupture of the latter artery. The histologic findings were consistent with remote Kawasaki disease. Giant coronary artery aneurysms are a rare complication of Kawasaki disease, infectious vasculitis, and atherosclerosis, among other causes. While Kawasaki disease is typically considered a disease of children, late-onset complications should be considered in the differential diagnosis of young adults with myocardial infarction, coronary aneurysm, or sudden death.

Current characteristics of congenital coronary artery fistulas in adults: A decade of global experience

AIM

To describe the characteristics of coronary artery fistulas (CAFs) in adults, including donor vessels and whether termination was cameral or vascular.

METHODS

A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults. A group of 304 adults was collected. Clinical data, presentations, diagnostic modalities, angiographic fistula findings and treatment strategies were gathered and analyzed. With regard to CAF origin, the subjects were tabulated into unilateral, bilateral or multilateral fistulas and compared. The group was stratified into two major subsets according to the mode of termination; coronary-cameral fistulas (CCFs) and coronary-vascular fistulas (CVFs). A comparison was made between the two subsets. Fistula-related major complications [aneurysm formation, infective endocarditis (IE), myocardial infarction (MI), rupture, pericardial effusion (PE) and tamponade] were described. Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery (PA).

RESULTS

A total of 304 adult subjects (47% male) with congenital CAFs were included. The mean age was 51.4 years (range, 18-86 years), with 20% older than 65 years of age. Dyspnea (31%), chest pain (23%) and angina pectoris (21%) were the prevalent clinical presentations. Continuous cardiac murmur was heard in 82% of the subjects. Of the applied diagnostic modalities, chest X-ray showed an abnormal shadow in 4% of the subjects. The cornerstone in establishing the diagnosis was echocardiography (68%), and conventional contrast coronary angiography (97%). However, multi-slice detector computed tomography was performed in 16%. The unilateral fistula originated from the left in 69% and from the right coronary artery in 31% of the subjects. Most patients (80%) had unilateral fistulas, 18% presented with bilateral fistulas and 2% with multilateral fistulas. Termination into the PA was reported in unilateral (44%), bilateral (73%) and multilateral (75%) fistulas. Fistulas with multiple origins (bilateral and multilateral) terminated more frequently into the PA (29%) than into other sites (10.6%) (P = 0.000). Aneurysmal formation was found in 14% of all subjects. Spontaneous rupture, PE and tamponade were reported in 2% of all subjects. In CCFs, the mean age was 46.2 years whereas in CVFs mean age was 55.6 years (P = 0.003). IE (4%) was exclusively associated with CCFs, while MI (2%) was only found in subjects with CVFs. Surgical ligation was frequently chosen for unilateral (57%), bilateral (51%) and multilateral fistulas (66%), but percutaneous therapeutic embolization (PTE) was increasingly reported (23%, 17% and 17%, respectively).

CONCLUSION

Congenital CAFs are currently detected in elderly patients. Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Acute myocardial infarction and the five-chambered heart

The case of a patient presenting with acute inferior ST-elevation myocardial infarction is described. Emergent coronary angiography of the right coronary artery revealed what appeared to be the abrupt drainage of contrast into a large, peculiar cavity or chamber. Echocardiography and cardiac computed tomography demonstrated a giant right coronary aneurysm in the right coronary artery that gave the impression of a "fifth heart chamber." The patient underwent successful surgical resection of the aneurysm. Diagnostic and treatment approaches to giant coronary aneurysms are discussed.

Surgical repair of coronary artery to pulmonary artery fistula with aneurysms

A 58-year-old female was referred to our hospital with an abnormal shadow on her chest X-ray. Further examination revealed the left anterior descending coronary artery to pulmonary artery fistula with aneurysms. The patient was successfully repaired with operation and had no residual fistulas and aneurysms.

A case of giant coronary artery aneurysm and literature review

A 40-year-old man was referred to our hospital because of an abnormal shadow on the left cardiac border on the chest roentgenogram at the regular medical health examination without any symptoms. A giant coronary artery aneurysm of left anterior descending artery with a maximum diameter of approximately 50 mm was detected with computed tomography and coronary angiography. The patient was treated and followed up medically. Four years later, the size of the coronary artery aneurysm became larger. Then resection of the coronary artery aneurysm and coronary artery bypass grafting were successfully performed. Coronary artery aneurysms are rare in adults and are usually found in association with Kawasaki disease, coronary atherosclerosis, and so on. We also review the literature of giant coronary artery aneurysms exceeding 50 mm in diameter.

Successful surgical treatment of a giant coronary artery aneurysm presenting with recurrent profuse haemoptysis

We present the case of successful resection of a giant aneurysm of the LAD presenting with recurrent severe haemoptysis in a 72-year old man. He was admitted to a regional hospital with fever, recurrent bloody sputum, weight loss and left sided chest pain, and developed respiratory failure requiring ventilation. Investigations are summarised and reviewed and the diagnosis was eventually reached by TTE, CT and MRI scans, confirmed by coronary angiography. Successful emergency surgery to resect the aneurysm and put a vein graft to the LAD is described. The presentation and management of coronary giant aneurysm is reviewed.

Giant right coronary artery aneurysm presenting as a paracardiac mass

Coronary artery aneurysms, commonly atherosclerotic, are usually asymptomatic and can be diagnosed incidentally during investigation for ischemic heart disease or on autopsy. An asymptomatic giant right coronary artery aneurysm presenting as a paracardiac mass discovered on autopsy is reported here. Even though there was great concern due to its large size, complex atherosclerotic lesions, and potential obstruction of blood flow, it had no direct link to the cause of death. We also review the literature on giant right coronary artery aneurysms exceeding 5 cm in the last 10 years.

Successful revascularization of multiple coronary artery aneurysms using a combination of surgical strategies

We report our approach to an unusual case of a 64-year-old man with multiple coronary artery aneurysms (CAAs) of the right, left anterior descending, and ramus coronary arteries. The right CAA was unusually large in size (measuring 5.5 cm). The aneurysms were obstructive, resulting in ischemic heart disease and heart failure. Multiple surgical techniques have been proposed to approach CAAs; however the ideal treatment strategy is poorly defined. This patient underwent successful revascularization using a combination of strategies, including aneurysm ligation, interposition reversed saphenous vein grafting, and bypass grafting. Surgical approach should be determined by aneurysm size, presence of branching vessels, and degree of stenosis.

A case of recurrent myocardial infarction caused by a giant right coronary artery aneurysm

We report a rare case of a giant coronary artery aneurysm with recurrent myocardial infarction (MI) in a 52-year-old man. He was admitted with severe chest pain and was diagnosed with acute MI. Ten days after thrombolysis, a transthoracic echocardiogram demonstrated a spherical mass apposed to the outer wall of the right atrium. Computed tomography with angiography showed this mass to be a huge aneurysm of the right coronary artery with a maximal diameter of 4 cm and filled with mural thrombus. Surgical resection of the aneurysm and coronary arterial bypass grafting were recommended. On day 60, while the patient awaited surgical treatment, recurrent MI caused by thrombotic occlusion occurred in the aneurysm site despite anticoagulant therapy. Two days after thrombolytic therapy, he underwent coronary artery bypass grafting and aneurysmal resection.

Giant intraatrial septal aneurysm originating from a branch of the left coronary artery

We present the case of a 38-year-old woman who had a large intraatrial aneurysm occupied by old thrombosis. The aneurysm was successfully removed, and the atrium was repaired. Pathohistological findings indicated that the inflow artery of the aneurysm had an anomalous origin from the left main coronary artery, and its pathogenesis was unknown. It is occasionally difficult to distinguish a large coronary aneurysm from a mediastinal tumor because this aneurysm is a rare entity, even more so in an atrial septum. A giant coronary aneurysm should be considered an alternative diagnosis in the event of a mediastinal mass. Surgery is recommended for a large coronary aneurysm.

Surgical treatment of giant coronary artery aneurysm

OBJECTIVE

Giant coronary artery aneurysm is an extremely uncommon disease. Most previous reports have involved only single cases. This report describes 6 patients with giant coronary artery aneurysm, examines its causes, and aims to establish the optimal surgical strategies for this exceptional and rare pathology.

METHODS

From July 1996 to October 2004, a total of 30,268 patients underwent heart surgery at Fuwai Hospital in Beijing. Among these, 6 patients had giant coronary artery aneurysm diagnosed and underwent operation. Various surgical strategies were used for the operations of these 6 patients, such as coronary artery aneurysm resection, coronary artery reconstruction, and concomitant coronary bypass. Additional procedures, such as fistula closure, aortic valve replacement, aortoplasty, and embolectomy, were done at same time for the patients with complications of coronary fistula, aortic valve insufficiency, or thrombus. Patients were followed up from 8 to 87 months, with a mean of 48 months. Doppler echocardiography, ultrafast computed tomography, and 3-dimensional aerial image studies were performed during follow-up.

RESULTS

Five of these six cases were found combined with coronary artery fistula, and the cause for these giant coronary artery aneurysms was congenital. The remaining case was caused by atherosclerosis. After surgery, all patients recovered uneventfully, without in-hospital mortality. None died during the follow-up, nor did any have recurrence of the symptoms or giant coronary artery aneurysm.

CONCLUSION

Giant coronary artery aneurysm is a rare entity that is commonly caused by congenital malformation and combined with other cardiac anomalies. An optimal surgical operation should be based on the specific cardiac anomaly of the individual patient.

Acute respiratory insufficiency and giant coronary artery aneurysm with fistula

Several causes of acute respiratory insufficiency have been reported in the literature. We describe a case in which it was caused by a rare combination of a giant right coronary artery aneurysm with fistula that occurred in a 56-year-old woman with concomitant congenital hypothyroidism. Diagnostic tools, differential diagnosis, surgical techniques, and follow-up at 1 year are discussed.