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CASE REPORT
Year : 2023 | Volume
: 9
| Issue : 1 | Page : 67-69
LMCA aneurysm and a fistula resulting with a giant extracardiac aneurysm
Kivanc Atilgan, Burak Emre Onuk, ER Zafer Cengiz, Fahri Gurkan Yesil, Abdullah Colak, Tayfun Aybek
Department of Cardiovascular Surgery, TOBB ETU Hospital, Ankara, Turkey
Correspondence Address:
Kivanc Atilgan
Department of Cardiovascular Surgery, TOBB ETU Hospital, Bestepe Mah, Yasam Cad, No: 5, TOBB ETU Hastanesi, Yenimahalle, Ankara
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_13_23
A 54-year-old, asymptomatic, disease-free female patient was operated for an incidentally detected left main coronary artery aneurysm (CAA) associated with fistula to a giant aneurysm associated with the right atrium (RA). The patient had an extremely rare left main CAA and a fistula connection of a giant aneurysm connecting to the RA.
Keywords: Coronary arteriovenous fistula, giant coronary artery aneurysm, left main coronary artery aneurysm
Coronary arteriovenous fistula (CAF) is observed in 0.1%–0.2% of patients undergoing coronary angiography (CAG). In approximately 15%–19% of patients with CAF, coronary artery aneurysm (CAA) is detected. It is mostly seen as a congenital pathology; however, it can be seen following thoracic trauma, cardiothoracic surgery, or coronary interventions.[1],[2] A left main coronary artery (LMCA) aneurysm combined with a fistulous connection to a giant aneurysm, which has a connection with the right atrium (RA), is an extremely rare finding as we are presenting in this case report.[3]
Case ReportA 54-year-old asymptomatic female without a history of any illness was referred to our clinic for incidentally found LMCA aneurysm with fistulous connection to a giant aneurysm, which has a connection with RA. At physical examination, there were normal hemodynamic parameters (blood pressure: 118,760 mmHg and heart rate: 84 bpm), normal SaO2 (96%), and body temperature 36°C. The electrocardiogram showed sinus rhythm. The transthoracic echocardiography detected an intrapericardial, giant aneurysm (maximum diameter 6 cm). A transesophageal echocardiography showed the giant aneurysm in connection with the RA [Figure 1] and [Figure 2]. Both of the two atriums were morphologically normal and showed no hemodynamic alteration due to compression or dislocation of the surrounding cardiac structures. Both ventricles showed normal dimensions and function. Mild range mitral and tricuspid valve insufficiencies were detected.
Figure 1: Preoperative TEE image (Arrow: Aneurysm with a 60 mm diameter). TEE: Transesophageal echocardiography
Figure 2: Preoperative TEE image (Arrow a: Anterior mitral leaflet; Arrow b: Aneurysmal section). TEE: Transesophageal echocardiography. LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle)A 16-sliced contrast-enhanced multidetector computed tomography (MDCT) was performed, and a giant aneurysm with a diameter of 59 mm × 54 mm placing next to the RA was identified [Figure 3]. The RA was morphologically grossly altered due to its extracardiac compression, without resulting with a hemodynamic issue. The proximal LMCA appeared ectasic with a diameter of 18 mm and showed a tortoise fistula to the giant aneurysm [Figure 4].
Figure 3: Preoperative MDCT image (Arrow: Aneurysm with a diameter of 5.89 cm × 5.54 cm). MDCT: Multidetector computed tomography
Figure 4: Preoperative MDCT image (Arrow: Aneurysmal origin of LMCA with a diameter of 1.89 cm). MDCT: Multidetector computed tomography; LMCA: Left main coronary arteryCAG was performed. The proximal part of LMCA was ectasic with a diameter of 18 mm and showed a tortoise fistula connected with giant aneurysm as detected in MDCT [Figure 5] and [Figure 6]. Atherosclerotic coronary artery disease was not detected.
Figure 5: Preoperative CAG image (Arrows: Aneurysmal section). CAG: Coronary angiography
Figure 6: Preoperative CAG image (Arrow: Aneurysmal origin of LMCA with a diameter of 18 mm). CAG: Coronary angiography; LMCA: Left main coronary artery; LAD: Left anterior descending arteryThe patient underwent an operation of a successful removal of aneurysm and was discharged on the postoperative 4th day following an uneventful hospitalization.
Operational technique
A median sternotomy was performed, and after a longitudinal pericardial opening, a giant aneurysm next to the RA with a thin thrill between the superior vena cava and right atrial auricula was observed [Figure 7]. After aortic and right atrial cannulation, the ascending aorta was cross-clamped, and the heart was arrested by antegrade cold blood cardioplegia. Aneurysmal tissue was dissected, and the right atrial fistula and the orifice of LMCA fistula were observed and sutured with a 4-0 Polypropylene suture. Aneurysmal tissue was removed [Figure 8]. The aortic cross-clamp time was 11 min, and the cardiopulmonary bypass time was 19 min.
Figure 7: Intraoperative image before removal of aneurysm (Arrow: Aneurysmal section). RA: Right atrium
Figure 8: Intraoperative image after removal of aneurysm (Arrow a: LMCA fistula orifice of aneurysm; Arrow b: Outlet of aneurysm). LMCA: Left main coronary artery; RA: Right atrium; VCI: Vena cava inferior Discussion CAF is a quite rare pathology and observed in 0.1%–0.2% of patients undergoing CAG. Although the most of the cases are seen as a congenital pathology, it may also occur after chest trauma, cardiothoracic surgery, or coronary interventions. In approximately 55% of the cases, it originates from the right coronary artery, 40% from the LMCA, and 5% from both. The usual drainage sites are the right ventricle in 41%, RA in 26%, pulmonary artery in 17%, coronary sinus in 7%, left ventricle in 3%, and superior vena cava in 1% of cases. A left-to-right shunt exists in more than 90% of cases. CAA also occurs in approximately 15%–19% of patients with CAF.[1],[2],[4]
Young patients are usually asymptomatic. However, serious complications such as arrhythmia, spontaneous rupture, bacterial endocarditis, myocardial ischemia, or congestive heart failure may develop.[5],[6] Left-to-right shunt through the fistula may cause a “steal” phenomenon causing a myocardial ischemia. Conservative management is recommended in asymptomatic patients; however, asymptomatic patients with large (>4 cm), rapidly growing CAA/fistulas or those with a left-to-right shunt (/) >1:1.5 require surgical repair and closure.[7]
The current treatment options for CAF and CAA include fistula surgical ligation, transcatheter closure of fistula, and surgical removal of aneurysm. In our case, the patient had no history of chest trauma, cardiac surgery, or coronary intervention. Although the patient had no symptoms, we recommended surgical intervention due to the giant aneurysm with a diameter of 60 mm.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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