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Left Main Coronary Artery Aneurysm and Associated Left Anterior Descending Coronary Artery Stenosis Treated with a Stent Graft
From the University of Toledo Medical Center, Division of Cardiovascular Medicine, Toledo, Ohio. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 22, 2009 and accepted February 11, 2009. Address for correspondence: Ehab A. Eltahawy, MD, MPH, University of Toledo Medical Center, Division of Cardiovascular Medicine, 3000 Arlington Avenue, Toledo, OH 43614.
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J INVASIVE CARDIOL 2009;21:E126-E127 Case Presentation. A 69-year-old male with a past history of two-vessel coronary artery bypass graft surgery (CABG) (left internal mammary artery-to-left circumflex artery; LIMA-LCX and saphenous vein graft-to-right coronary artery; SVG-to-RCA) in 1990 was referred for diagnostic cardiac catheterization due to an abnormal stress test ordered during preoperative evaluation for upcoming knee surgery. Apart from shortness of breath on exertion, the patient was asymptomatic, but his activity was limited due to knee pain. The stress test performed prior to coronary angiography revealed ischemia in the lateral and septal walls, with an ejection fraction (EF) of 29%. Coronary angiography showed an aneurysm involving the distal left main coronary artery (LMCA), and the proximal left anterior descending coronary artery (LAD) with a 70% stenosis just distal to the aneurysm (Figures 1 and 2). The LIMA graft to the LCx and the SVG to the RCA were patent. Percutaneous revascularization was thus planned. An 8 Fr arterial sheath was placed in the right femoral artery. A venous sheath and a 4 Fr arterial sheath were placed in the contralateral groin for hemodynamic monitoring and potential intra-aortic balloon pump (IABP) placement, respectively. Intravascular ultrasound (IVUS) assessment was performed using an 8 Fr XB 3.5 guide catheter, an Asahi Light coronary guidewire (Asahi Intecc Co. Ltd., Nagoya, Japan) and a Volcano Eagle Eye® catheter (Volcano Corp., San Diego, California). After IVUS imaging, we elected to proceed with angioplasty and stent graft placement. A Stabilizer® Plus coronary guidewire (Cordis Corp., Miami Lakes, Florida) was exchanged in for the Asahi Light guidewire utilizing a 3.0 x 15 mm Quantum™ Maverick® balloon (Boston Scientific Corp., Natick, Massachusetts). Angioplasty was performed (Figure 3), followed by placement of a 4.0 x 16 mm Jostent® GraftMaster stent graft (Abbott Vascular, Abbott Park, Illinois). Postdilatation was performed using a 4.0 x 15 mm Quantum Maverick and a 4.5 x 9 mm NC Monorail balloon (Boston Scientific). Following this, angiography was repeated; now revealing excellent results at the site of the left main coronary artery stenosis (Figure 4). Angiography of the left internal mammary artery bypass graft to the left circumflex coronary artery confirmed that there was complete flow into the left circumflex coronary artery (Figure 5) which had been occluded by placement of the stent graft across its ostium. Discussion. Aneurysmal coronary artery disease (CAD) is an abnormal dilatation of a localized or diffuse segment of the coronary artery tree also termed ‘coronary artery ectasia’ (CAE). Based on the Coronary Artery Surgery Study (CASS) registry, a coronary dilatation with a diameter of ≥ 1.5 times the adjacent normal segment2 is defined as CAE. It is found in 0.3–5% of patients undergoing coronary angiography.1 The proximal and middle segments of the RCA are the most common sites for CAE (68%) followed by the proximal LAD (60%) and the LCx (50%); coronary artery ectasia of the LMCA is rare and occurs in only 0.1% of the population.3–5 Complications such as thrombus formation, distal embolization and shunt formation and rupture can occur, but the absolute risk is not known. Rapid enlargement of coronary aneurysms has been reported.6,7 In addition, CAE may be associated with concomitant aneurysms in different arterial beds.1 Treatment can be conservative, or may involve percutaneous or surgical revascularization. To avoid thromboembolism, antiplatelet and anticoagulation therapies are reasonable and probably beneficial despite lacking evidence-based medicine.8 Especially with accompanying stenosis, the use of grafted stents is advocated. The Jostent® polytertafluoroethylene (PTFE)-covered, balloon-expandable stent has been shown to be an effective device for the percutaneous management and exclusion of coronary aneurysms.9–11 Because of the rarity of LMCA aneurysm, it is difficult to standardize treatment. There are also few reports of surgical treatment of LMCA aneurysms. Surgical therapy is usually reserved for those with large thrombotic aneurysms or with myocardial ischemia and significant associated CAD.5,12 Coronary artery aneurysms are uncommon angiographic findings with variable clinical and angiographic characteristics. There are no clear guidelines as to the best management strategy. Stent grafts are a potential option, particularly when accompanied by coronary stenoses.
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