Case Report:
A 47-year-old Hypertensive, non-insulin dependent diabetic gentleman
presented to the emergency department with recurrent attacks of chest
pain suggesting unstable angina. His diagnostic workup included blood
tests, Echocardiography, left heart catheterization which demonstrated a
huge dilatation of the right coronary artery with proximal and distal
stenosis (Figure IA), and multi-vessel coronary artery disease involving
the left coronary system (Figure IB) and Contrast-enhanced chest CT
(Figure IC). In the present case, our patient had 3 vessel coronary
artery disease with strong symptoms, and also having right sided
dominant circulation with a posterior descending artery measuring 1.5 mm
in diameter, and no major branch such as marginal or sinoatrial arteries
could be demonstrated to take off from the giant right coronary aneurysm
by examining various views of the right coronary angiogram. In the view
of the patient presentation and the presence of multi-vessel coronary
artery disease and the presence of the giant right coronary artery
aneurysm, decision was taken to offer our patient the option of coronary
artery bypass grafting with ligation of the right coronary artery
aneurysm.
Surgery was performed via median sternotomy; the left internal thoracic
artery (LITA) and left great saphenous vein (GSV) were harvested as
conduits. Routine Cardiopulmonary bypass and cardioplegia was used. The
right coronary artery aneurysm was isolated proximally and distally. It
was then ligated with Proline 4/0 threads (Figure I D), Extreme caution
was taken not to excessively mobilize the giant aneurysm in order to
prevent distal embolization of calcium or debris into the distal right
coronary artery territory. Luckily, there were no branches in the RCA at
the location of the aneurysm, and distal to the ligation, the posterior
descending branch of the RCA was grafted with saphenous vein. Remaining
part of the procedure was completed and patient weaned uneventfully off
cardiopulmonary bypass with good ventricular function and in normal
sinus rhythm. Dual antiplatelet therapy was initiated in the second day
postoperatively.