Discussion
Giant coronary artery aneurysms are extremely rare; is an extremely rare
condition, with a reported incidence of 0.02%, among patients
undergoing coronary angiography with a predilection to the right
coronary artery, followed by the left anterior descending, left main
coronary artery and circumflex artery (4). An increasing incidence had
been reported after the wide spread utilization of drug eluting stents,
possibly due to the arterial wall damage during balloon angioplasty or
during stent deployment (5). Majority of coronary artery aneurysms are
asymptomatic and discovered during diagnostic angiography, however giant
coronary artery aneurysms may present with complications such as
rupture, thrombo-embolic phenomena, arrhythmias, vasospasm or rarely it
may form a communicating fistula with a heart chamber depending on the
size, extent of involvement and status of the other coronary arteries
(6).
The pathogenesis of such coronary aneurysm is due to weakness of the
arterial wall of the coronary artery which leads to arterial dilatation.
Multiple etiologies have been linked to this pathology including
atherosclerosis, Kawasaki disease, vasculitis, hypercholesteremia and
blunt trauma (7). In our case, atherosclerosis is the most probable
etiology, since our patient is having strong risk factors for
atherosclerosis including, systemic hypertension, heavy smoking,
uncontrolled diabetes mellites and abnormally elevated lipid profile
readings ( LDL = 139 mg/dl, Total Cholesterol = 256 mg/dl).
In the absence of solid consensus for the best management of coronary
aneurysms, variation of strategies had been adopted amongst reported
cases and decision being made based on the aneurysmal size, location,
symptomatology status and severity of the coronary artery disease (4).
For smaller size coronary artery aneurysms with minimal symptoms,
conservative treatment including antiplatelet therapy with modification
of the cardiovascular risk factors are usually sufficient (4). For those
who have giant aneurysms and carrying prohibitive risk for surgery,
percutaneous coronary intervention using covered stents or coil
embolization had been described (4). Surgery including aneurysmal
ligation or resection remains the preferred approach for giant coronary
artery aneurysms because it can prevent complications and treat
associated surgical conditions (5). We hence elected this method for our
patient and performed coronary artery bypass grafting to the left
coronary circulation with proximal and distal ligation of the giant
right coronary aneurysm and bypassing the posterior descending
artery-using piece of saphenous vein graft. We created a summarized
flowchart demonstrating the management strategies for giant coronary
artery aneurysm (Table 1)
Conclusion:
Our case highlights the importance of thorough diagnostic assessment for
such coronary aneurysm before decision making plan. Combined coronary
artery bypass grafting with aneurysmal exclusion is a valid option.
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