Surgical Management of Giant Left Anterior Descending Artery Aneurysm Post Stent

A 68-year-old male presented with chest pain and breathlessness on exertion during the preceding 10 days. He had undergone percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending artery (LAD) the previous year and had a history of hypertension (HTN) and hypothyroidism, with no history of fever. Preoperative evaluation, including a CT coronary angiogram, revealed a well-defined aneurysmal sac measuring 4.3cm x 3cm in the left anterior mediastinum, with peripheral mural thrombus, and an overall measurement of 6.4 cm X 5 cm. The LAD stent appeared to extend through the aneurysmal sac, causing compression of the adjacent main pulmonary artery. Coronary angiogram confirmed coronary artery disease (CAD) and triple vessel disease (TVD) with the presence of the LAD aneurysm.  

The patient underwent surgical repair of the LAD aneurysm and coronary artery bypass grafting. A midline sternotomy was performed, and the left internal mammary artery (LIMA) and saphenous vein graft (VG) were harvested.  

The patient then underwent cardiopulmonary bypass (CPB) with aortoatrial cannulation, during which the aorta was clamped. Antegrade and retrograde cardioplegia were administered. The aneurysm was opened, and clots and a stent were removed. The proximal and distal opening of the LAD in the aneurysm sac were closed using pledgetted sutures. The aneurysmal sac was plicated and closed with Teflon strips after excising the redundunt sac.  

Distal coronary anastomosis was performed left internal mammary artery (LIMA) to distal LAD, saphenous vein graft (SVG) to obtuse marginal (OM) artery, and SVG to posterior descending artery (PDA). The patient was easily weaned from CPB, and the operation was completed as planned. Transesophageal echocardiography showed no regional wall motion abnormalities. The patient was weaned from mechanical ventilation after a few hours and had an uneventful postoperative course. On the eighth postoperative day, the patient was discharged home and was treated with six weeks of antibiotics therapy. 
 
Histological examination of the aneurysmal sac showed fibrocollagenous connective tissue with foci of fibrinoid necrosis and mild chronic inflammation, composed of polymorphs, lymphocytes, and a few histiocytes. There was no evidence of granuloma or maliginancy. A culture and sensitivity test of the aneurysmal sac revealed the presence of Pseudomonas aeruginosa.  

References

1. Naraen A, Reddy P, Notarstefano C, Kudavali M. Giant Coronary Artery Aneurysm in a Middle-Aged Woman. Ann Thorac Surg. 2017 Apr;103(4):e313-e315. doi: 10.1016/j.athoracsur.2016.09.018.
2. Alexander Rutherford, Badrinathan Chandrasekaran, Mario Petrou, Steve Ramcharitar, Giant proximal left anterior descending aneurysm causing multi-vessel myocardial ischaemia: the pressure is on—a case report, European Heart Journal - Case Reports, Volume 7, Issue 11, November 2023, ytad550
3. Sushil Kumar Singh, Tushar Goyal, Rishi Sethi, Sharad Chandra, Vijayant Devenraj, Nitin Kumar Rajput, Dinesh Kaushal, Vivek Tewarson, Santosh Gupta, Sarvesh Kumar, Surgical treatment for coronary artery aneurysm: a single-centre experience, Interactive CardioVascular and Thoracic Surgery, Volume 17, Issue 4, October 2013, Pages 632–636
4. Peng, Y., Li, Y. & Jiang, Y. Rare case of a giant thrombosed left anterior descending coronary artery aneurysm. J Cardiothorac Surg 15, 204 (2020)

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