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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