Rare Case of a Patient Who Survived This Cardiovascular Condition

A 64-year-old man presented to a cardiovascular clinic after being referred for assessment of chest pain and shortness of breath on exertion. He had high blood pressure and benign prostate hypertrophy, and was described as being addicted to opium.

His medications included a proton pump inhibitor, a calcium channel blocker, an angiotensin II receptor antagonist, a statin, and aspirin (80 mg daily).

His weight was about 151 kg (332 lbs), and his body mass index was about 46, classified as being morbidly obese.

Clinicians performed coronary angiography, which identified a giant aneurysm at the origin of the left anterior descending (LAD) artery.

Surgeons performed cardiac surgery, which revealed a clot-filled coronary aneurysm of about 42 mm; it was located behind the pulmonary artery, resulting in compression of the artery.

The aneurysm had openings to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. Surgeons determined that the border of the aneurysm should be preserved to avoid compromising the orifices. In excising the aneurysm, the team also preserved the floor.

After the aneurysm was removed, the patient underwent a coronary artery bypass graft, for which clinicians used the radial artery to the LAD. Flowmetry testing showed that there was a good flow in the LAD.

The surgery was successful, the patient recovered well, and was discharged.

Discussion

Clinicians reporting this case of a morbidly obese man with a giant coronary artery aneurysm (GCAA) emphasized the importance of timely treatment, to prevent potentially fatal complications such as acute myocardial infarction, ventricular tachycardia, and thrombosis.

CAAs are called giant when the diameter is more than four times the adjacent blood vessel, or more than 8 mm. GCAA is uncommon, with an incidence of about 0.02% compared with 1.5% to 5% for coronary artery aneurysm, and there is no standard surgical approach, the case authors noted.

Etiologies include atherosclerosis, which accounts for 50% of cases, Kawasaki disease, and trauma. GCAAs typically occur in the epicardial coronary arteries. The proximal and middle segments of the right coronary artery are most commonly affected (about 68% of cases), followed by the proximal LAD (60%) and left circumflex (50%).

CAA of the left main stem is exceedingly rare and occurs in only about 0.1% of the population.

Symptoms of GCAA often include chest pain, dyspnea, and palpitations, although some patients may not have symptoms.

The case authors cited several reports of fatal GCAA, one in a 5-year-old boy with an LAD giant aneurysm, who died of cardiac arrest; another of a 49-year-old man who did not tolerate surgery and died; and another of a 56-year-old man with a giant aneurysm measuring 70 × 40 mm who declined surgical treatment and died a month after diagnosis.

Surgical management of GCAA varies, ranging from aneurysm resection to coronary artery reconstruction, and selecting the surgical method best suited to the individual patient can be a life-saving decision, the case authors noted.

High-risk patients may benefit from percutaneous procedures such as coronary artery stenting, occluding with a detachable balloon or detachable coil, the team continued. Surgical removal of the aneurysm from the affected coronary artery can be achieved with percutaneous stenting of the coronary artery, but percutaneous interventions can have both short- and long-term complications, including thrombosis, dissection, and no re-flow.

Regarding this patient's addiction to opium, the case authors explained that the condition of coronary artery ectasis -- i.e., dilatation of an arterial segment to a diameter at least 1.5 times that of the adjacent normal coronary artery -- is more prevalent in patients with that problem.

Conclusion

The authors concluded that GCAAs are rare and patients may experience sudden death due to myocardial infarction, ischemia, and other cardiovascular complications. This patient's case is one of the few reports in the literature of someone who survived GCAA. And since there is as yet no standardized surgical approach, the team urged further studies to help determine what technique is best.

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