Surgical Treatment for a Super-Giant Right Coronary Artery Aneurysm Induced by Kawasaki Disease

Abstract A 32-year-old man diagnosed with Kawasaki disease at the age of three years presented with coronary artery aneurysm (CAA). The aneurysm increased in size, and the patient was referred to our hospital for surgery. Preoperative computed tomography scan showed a super-giant right CAA and giant left CAAs; surgery was performed. The super-giant right CAA was resected, and the ostium of the right coronary artery was closed; then, coronary artery bypass grafting was performed. The left CAAs were not treated surgically because the risk of rupture was low. Here, we describe the successful surgical treatment of a right super-giant CAA.

Ligature of the left main coronary artery after surgery in kawasaki disease: case report

Abstract We report a case of a 23-year-old man who was diagnosed with Kawasaki disease that progressed to a coronary aneurysm in the left main coronary artery (LMA). He had suffered from acute coronary syndrome and then underwent an emergent percutaneous coronary angioplasty, in which a polyurethane-covered stent was placed inside the aneurysm. The stent was thrombosed one year later, despite the patient had been treated with anticoagulant and antiplatelet therapy. Emergency percutaneous intervention was then performed. LMA was reopened and stent malposition was observed. Therefore, urgent coronary bypass grafting was performed in which a high degree of competitive flow was observed through the reopened stent. LMA was ligated at the inflow of the aneurysm, resulting in an improvement of graft flow. Left main ligature has not been previously reported.

Giant right coronary artery aneurysm with unusual physiology: Role of intraoperative transesophageal echocardiography.

A 65-year-old woman presented with a history of dyspnea and atypical chest pain. She was diagnosed with a non-ST-segment elevation myocardial infarction due to a giant right coronary artery aneurysm. After a failed percutaneous embolization, she was scheduled for right coronary artery aneurysm resection, posterior descending artery revascularization and mitral valve repair. During the induction of anesthesia and institution of mechanical ventilation, the patient suffered cardiovascular collapse. The transesophageal echocardiographic examination revealed tamponade physiology owing to compression of the cardiac chambers by the unruptured aneurysm, which resolved with the sternotomy. The surgery was carried out uneventfully.

Revascularização cirúrgica miocárdica (RCM) na presença de aneurismas coronarianos / Coronary artery bypass graft (CABG) in the presence of coronary aneurysms / Revascularización quirúrgica miocárdica (RQM) en la presencia de aneurismas coronarios

É descrito caso de paciente portador de volumosos aneurismas coronários, submetidos à RCM, na qual foi adotada a exclusão cirúrgica destes aneurismas, seguido do implante de pontes de safena para as artérias comprometidas, com resultado a curto e longo prazos satisfatório.

This is the case of a patient with coronary aneurysms, who underwent CABG for surgical exclusion of these aneurysms, followed by implant of the bypass grafts to the arteries affected, with satisfactory short-term and long-term results.

Se describe el caso de un paciente con aneurismas coronarios voluminosos, que fueron sometidos a RQM, en la que se adoptó la exclusión quirúrgica de estos aneurismas, seguida de la implantación de puentes de safena para las arterias en peligro, con resultado a corto y largo plazos satisfactorio.

Tratamento operatório da dissecção iatrogênica do tronco de coronária esquerda / Operative treatment after iatrogenic left main dissection

A dissecção coronária iatrogênica apresenta alta morbidade e mortalidade. Diante da oclusão aguda do fluxo coronariano, é fundamental a restauração imediata da perviabilidade do vaso para limitar a extensão e duração da isquemia. Nesta situação, pode estar indicada a revascularização cirúrgica do miocárdio de emergência. Os autores apresentam caso de um paciente com dissecção iatrogênica do tronco de coronária esquerda durante angioplastia transluminal percutânea, que foi solucionada pela realização de revascularização completa do miocárdio, com resultado satisfatório.

Coronary dissection has a significant morbity and mortality. The ideal management of acute coronary occlusion is the prompt restoration of the vessel patency to limit the extent and duration of ischemia. In the setting of dissection during percutaneous procedure, the usual approach has been emergency aortocoronary bypass surgery. The authors present a case of a patient with left main dissection during percutaneous transluminal coronary angioplasty. This problem was successfully managed with emergent aortocoronary bypass surgery.

Aneurisma do tronco da artéria coronária esquerda / Aneurysm of the left main coronary artery

O aneurisma do tronco da artéria coronária esquerda é extremamente raro e resulta de doença coronariana grave, com poucos casos descritos na literatura. A mortalidade é elevada e a terapêutica ainda é controversa. Relatamos o caso de uma paciente de 61 anos, admitida no pronto-socorro de hospital universitário, com quadro clínico de síndrome coronariana aguda, cuja coronariografia demostrou a presença de aneurisma gigante de tronco da artéria esquerda. A paciente foi submetida a tratamento cirúrgico e permanece assintomática após um ano de acompanhamento ambulatorial.

Aneurysm in the coronary trunk is an uncommon angiographic finding, with few cases reported. The mortality is high and the therapeutics are still uncertain. The aneurysm of the left main coronary artery is a rare and the worse cause of coronary artery disease. We report a case of a 61-year-old-female patient admitted in the Hospital Emergency Unit with a history of acute coronary syndrome. Coronary angiography showed a giant aneurysm in the left main coronary artery. The patient was submitted to coronary artery bypass grafting and remains asymptomatic after a one-year follow-up.

Aneurisma coronário após implante de stent com eluição de fármaco / Coronary aneurysm after drug-eluting stent implantation

A utilização de stents com eluição de fármacos com a finalidade de contornar as desvantagens dos stents não farmacológicos tem sido associada a trombose tardia após a retirada dos agentes antiplaquetários. Relatamos aqui o caso de outra complicação, a formação de aneurisma coronário adjacente ao stent farmacológico, após mais de três anos de implante. As respostas inflamatórias arteriais crônicas locais podem ser as responsáveis pelo enfraquecimento, erosão e formação aneurismática.

The use of drug-eluting stents aiming at by-pass the disadvantage of stainless steel stents have been associated to late thrombosis after withdrawal of anti-platelet agents. We report a case with another complication, the development of a coronary aneurysm in the stent area more than three years after index procedure. Late chronic local inflammatory responses may be responsible for the weakening, erosion and aneusrysm formation.

Enfermedad coronaria aneurism tica severa en un adolescente con angina de esfuerzo secundaria a enfermedad de Kawasaki no diagnosticada previamente / Severe aneurisma I coronary artery disease probably caused by Kawasaki disease. Report of one case

We report a 16 year old male with a history of angina on exertion. A treadmill exercise test was positive for ischemia in concordance with a Thallium-201 scintigraphy showing a septal and infero-posterior reversible myocardial perfusi¢n defect. Coronary angiography disclosed severe aneurysmal coronary artery disease. Bilateral internal mammary coronary artery bypass grafting was successfully performed. Kawasaki disease is the most likely etiology, although not confirmed.

Muerte súbita, taponamiento y síndrome coronario agudo como manifestación clínica de un aneurisma coronario gigante / Sudden death, tamponade and acute coronaey syndrome as the clinical presentation of a giant coronary aneurysm

Los aneurismas coronarios son una patología infrecuente (0,5-3 por ciento de incidencia). Suelen asociarse con estenosis coronarias y la aterosclerosis es la etiología más frecuente. Nuestro paciente debutó con muerte súbita. Posteriormente presentó taponamiento cardíaco y a las 24 horas desarrolló un IAM inferior. La coronariografía mostró una gran dilatación esferoidal (4,5 × 5 cm) en la coronaria derecha proximal. Se trató con resección del aneurisma y puente aortocoronario. La evolución suele ser asintomática. La rotura o la muerte súbita son formas raras de presentación. La actitud conservadora es el tratamiento más comúnmente aplicado. La indicación quirúrgica dependerá de la presencia de estenosis coronarias asociadas o de la existencia de complicaciones.

Disección espontánea de la arteria coronaria descendente anterior tratada mediante cirugía sin circulación extracorpórea / Surgical treatment of a spontaneous dissection of the left anterior descending coronary artery without the use of cardiopulmonary bypass

Se presenta un caso de disección espontánea de la arteria coronaria descendente anterior en una mujer de 51 años, sin relación con factores desencadenantes conocidos. El inicio clínico fue un IAM no Q anterior, controlado con tratamiento médico y buena evolución clínica. El cateterismo cardíaco evidenció la disección de la arteria descendente anterior, que producía deterioro de la función sistólica. Se realizó revascularización arterial urgente mediante injerto de mamaria interna izquierda a descendente anterior sin CEC. El posoperatorio cursó sin complicaciones y a 25 meses del procedimiento la paciente se encuentra asintomática. Se realiza, además, una exposición de las consideraciones clínicas relacionadas con esta patología.

Aplicaciones del stent cubierto con membrana de politetrafluoroetileno en el intervencionismo coronario (Experiencia del Instituto Nacional de Cardiología "Ignacio Chávez") / Synthetic membrane coronary stent graft in coronary disease

El stent cubierto con membrana se ha reportado como un dispositivo útil para corregir lesiones angiográficas específicas, así como complicaciones potenciales secundarias a procedimientos de intervencionismo coronario. El stent cubierto con membrana de (Jostent-Jomed) está compuesto por una fina capa de politetrafluoroetileno (PTFE) que se localiza entre dos stents metálicos. En esta revisión retrospectiva el stent de PTFE se utilizó en varias lesiones y situaciones angiográficas tanto en arterias coronarias como en injertos venosos. Nuestra experiencia consistió de 17 pacientes que fueron tratados por diferentes indicaciones clínicas y angiográficas: perforación coronaria en dos pacientes (pts), injertos venosos con trombo y cambios degenerativos en ocho (pts), aneurismas coronarios en 4 (pts) y trombo grande refractario a tratamiento habitual en otros 3 casos. Nuestros resultados con el stent de PTFE mostraron una tasa de éxito clínico del 100% sin complicaciones durante la fase hospitalaria y en el seguimiento clínico a 10 ± 3 meses sólo tres pacientes tuvieron algún evento cardíaco adverso mayor. La indicación potencial para el implante del stent de PTFE en injertos venosos todavía no se ha puntualizado; sin embargo a la luz de varios estudios pareciera haber poco beneficio en esta circunstancia. Por otro lado la perforación y el aneurisma coronario parecen ser las indicaciones más recomendables para la aplicación de este dispositivo.

Summary The use of a synthetic membrane-covered stent has been suggested to overcome some specific lesions in coronary arteries and to solve some potential complications that could arise in any procedure of coronary intervention. A synthetic membrane coronary stent graft (JOSTENT-JOMED) is constituted by a membrane of polytetrafluoroethylene (PTFE), fixed between two thin metallic stents. In this clinical review of our laboratory's experience, the Jostent graft was used in several angiographic circumstances in coronary arteries or in vein grafts. Our clinical experience consists of 17 patients that were treated with placement of PTFE stents for different indications: coronary rupture in two patients; thrombus and degenerative vein grafts in eight patients, coronary aneurysms in four patients, and thrombus in coronary arteries in three more. Our clinical results with this device suggest that its implant is feasible and safe with a clinical success of 100% without complications during in-hospital stay; during the clinical 11 ± 3 months follow-up, only three patients exhibited major cardiac events. The indication for PTFE stent in vein grafts with degenerative and thrombus lesions has not been determined yet; however, recently, some randomized trials have shown little benefit in this circumstance. On the other side, coronary vessel rupture and coronary aneurysms are currently the most definitive indications.