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Successful surgical treatment of a giant coronary artery aneurysm presenting with recurrent profuse haemoptysis
© Mensah et al; licensee BioMed Central Ltd. 2008
Received: 12 July 2007
Accepted: 29 June 2008
Published: 29 June 2008
We present the case of successful resection of a giant aneurysm of the LAD presenting with recurrent severe haemoptysis in a 72-year old man. He was admitted to a regional hospital with fever, recurrent bloody sputum, weight loss and left sided chest pain, and developed respiratory failure requiring ventilation. Investigations are summarised and reviewed and the diagnosis was eventually reached by TTE, CT and MRI scans, confirmed by coronary angiography. Successful emergency surgery to resect the aneurysm and put a vein graft to the LAD is described. The presentation and management of coronary giant aneurysm is reviewed.
Coronary artery aneurysm is a clinical entity, which is found rarely during coronary angiography. Most patients have typical coronary artery disease symptoms. We present here a case of a giant coronary artery aneurysm of the LAD presenting with recurrent profuse haemoptysis.
The patient was transferred to the Intensive Care Unit where after a period of inotropic support, he was stabilised and extubated on the 2nd post-operative day but developed respiratory insufficiency requiring 5 further days of ventilation. He was discharged well on the 27th post-operative day and had no further events at follow up to 7 months.
Coronary artery aneurysm is found in only about 0.15% to 4.9% of patients who undergo coronary angiography . Aneurysmal diameter varies from 1.5 – 2 × that of the largest coronary artery, up to the so-called giant aneurysm with a diameter of 5 cm to 15 cm [2, 3]. Its aetiology may be congenital, or acquired through atherosclerosis, Kawasaki disease, complications of percutaneous coronary artery angioplasty, chest trauma  and rarely cocaine abuse . There is geographic variation with atherosclerotic aneurysm found mainly in patients of European origin, whereas the giant aneurysm found characteristically in Kawasaki disease occurs predominantly in Japanese, Chinese and other Asian ancestries.
The gold standard diagnostic imaging procedure is coronary angiography to confirm the origin from a coronary vessel, its size and fistulous communication to other structures. In most cases the diagnosis is already suspected following CT or MRI scanning performed to define a mass lesion, which may suggest a vascular aneurysm in proximity to the epicardial surface as in our patient.
Therapeutic options include surgery or percutaneous coronary stenting combined with adjuvant antiplatelet and anticoagulant agents. Median sternotomy and hypothermic cardiopulmonary bypass are usually utilised. In cases where there is a very large aneurysm with extensive pericardial adhesions, peripheral cannulation for institution of bypass and cooling prior to opening the chest may be prudent . In the case presented, we were confident to perform sternotomy and to free the anterior portion of the ascending aorta and the right atrium for standard cannulation because the aneurysm was clearly lateral to these structures and could be left undisturbed until the aorta had been clamped. Our rational for this approach was to avoid any catastrophic bleeding as well as distal coronary artery embolization. We did not do any extensive dissection of the left upper lobe in order to avoid any injury to the lung.
There have been case reports presenting various intra operative findings such as fistulae from the aneurysm to a cardiac chamber . In the case presented here, we did not find any clear fistula on the basis of the coronary angiography nor in the CT and MRI. In the bronchoscopy no definitive bleeding source could be found. During the operation we could not find any direct vascular connection between the left upper lobe and the aneurysm and the haemoptysis resulted from bronchial bleeding points which, in our opinion, resulted from the compression exerted by the giant aneurysm through the pericardial wall. The absence of any bronchial tumor in the bronchoscopy as well as the bleeding from the ulcerated gastrooesphageal junction observed at gastroscopy did blur the clinical picture and delayed the definitive diagnosis.
The case presented had a protracted preoperative diagnostic course which may have resulted in life threatening haemorrhage or rupture prior to surgical intervention. Transthoracic echocardiography, chest CT, MRI and coronary angiography were of assistance in arriving at a final and correct diagnosis. We would encourage consideration of a possible intrathoracic aneurysm, for example a giant coronary artery aneurysm, although it is rare, in a patient with haemoptysis and an abnormal mediastinal contour in the presence of normal bronchoscopy.
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
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