Ann Thorac Surg
2000;70:1397– 8
rysm. In cases with fistula, closure of the fistula is
needed. When native coronary blood flow is compro-
mised, a bypass graft is essential. Management of the
cases in Table 1 approximately followed these lines.
The present case was asymptomatic, but we opted to
operate because of the large size of the aneurysm and
high risk of rupture. The left-right shunt ratio was 20%;
thus there was a risk of congestive heart failure. Further-
more, the aneurysm compromised normal blood flow to
the RCA.
References
1. Oliveros RA, Falsetti HL, Carroll RJ, Heinle RA, Ryan GF.
Atherosclerotic coronary artery aneurysm. Arch Intern Med
1974;134:1072– 6.
2. Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary
artery disease. Circulation 1983;67:134– 8.
3. Wenger NK. Rare causes of coronary artery disease. In: Hurst
JW, ed. The heart. New York: McGraw-Hill, 1978:1348 –9.
4. Vranckx P, Pirot L, Benit E. Giant left main coronary artery
aneurysm in association with severe atherosclerotic coronary
disease. Cathet Cardiovasc Diagn 1997;42:54–7.
5. Gersony WM. Diagnosis and management of Kawasaki dis-
ease. JAMA 1991;265:2699 –703.
Interposition Vein Graft for Giant
Coronary Aneurysm Repair
Michael S. Firstenberg, MD, Fouad Azoury, MD, Bruce
W. Lytle, MD, and James D. Thomas, MD
Department of Thoracic and Cardiovascular Surgery, The
Cleveland Clinic Foundation, Cleveland, Ohio
Coronary aneurysms in adults are rare. Surgical treat-
ment is often concomitant to treating obstructing coro-
nary lesions. However, the ideal treatment strategy is
poorly defined. We present a case of successful treatment
of a large coronary artery aneurysm with a reverse
saphenous interposition vein graft. This modality offers
important benefits over other current surgical and percu-
taneous techniques and should be considered as an
option for patients requiring treatment for coronary an-
eurysms.
(Ann Thorac Surg 2000;70:1397– 8)
© 2000 by The Society of Thoracic Surgeons
C oronary aneurysms are rare. In the United States
they are encountered in 1.5% to 5% of patients
undergoing elective coronary angiography and typically
involve the right coronary artery [1]. Risks include spon-
Accepted for publication Feb 23, 2000.
Address reprint requests to Dr Thomas, Department of Cardiology, Desk
F15, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland,
OH 44195; e-mail: thomasj@cesmtp.ccf.org.
© 2000 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
CASE REPORT FIRSTENBERG ET AL 1397
INTERPOSITION GRAFT FOR CORONARY ANEURYSMS
taneous rupture [2] or thrombotic or embolic complica-
tions [3], and they complicate the evaluation of distal
coronary anatomy during angiography. However, the
natural history of coronary aneurysms is unknown. Typ-
ically, aneurysms are repaired during concomitant treat-
ment of obstructive coronary lesions, and multiple sur-
gical options have been described. We present a patient
successfully treated with a reverse saphenous interposi-
tion vein graft.
A 73-year-old woman presented with complaints of
worsening exertional chest pain and shortness of breath.
Cardiac catheterization demonstrated a large proximal–
mid right coronary artery aneurysm (Fig 1). Intraopera-
tive findings confirmed the preoperative diagnosis (Fig
2). Marsupialization of the aneurysm revealed no intra-
cavitary thrombus or significant branching vessels. A
short segment of reversed saphenous vein was anasto-
mosed to the proximal and distal openings of the aneu-
rysm (Fig 3). Owing to the poorly defined preoperative
distal anatomy by the dilutional effect of the large aneu-
rysm, an additional vein graft off the aorta was placed to
the distal right coronary artery. On postoperative day 2,
repeat cardiac catheterization demonstrated widely
patent grafts and moderate stenosis of the native coro-
nary artery distal to the interposition graft (Fig 4).
Comment
Current treatment options for coronary aneurysms in-
clude coronary artery bypass grafting, usually in con-
junction with proximal or distal ligation. Other surgical
options include resection with end-to-end anastomosis
[4]. We present a case demonstrating an alternative
method for the treatment of coronary artery aneurysms.
The use of an interposition vein graft offers significant
advantages over other currently used treatment methods.
Fig 1. Preoperative cardiac catheterization demonstrates a signifi-
cant isolated right coronary artery (RCA) aneurysm.
0003-4975/00/$20.00
PII S0003-4975(00)01579-4
1398 CASE REPORT FIRSTENBERG ET AL
INTERPOSITION GRAFT FOR CORONARY ANEURYSMS
Fig 2. Intraoperative transesophageal echocardiography illustrates
the aneurysm with the proximal and distal portions of the right cor-
onary artery (RCA). (Ao ⫽ aorta; LA ⫽ left atrium; RA ⫽ right
atrium.)
Preservation of the normal coronary artery flow pat-
tern with an interposition graft has several advantages
over other techniques. Proximal or distal ligation risks
causing myocardial ischemia. Postoperative angiography
in our patient demonstrated a right ventricular branch
distal to the repair that was not visualized preoperatively.
Even with meticulous dissection, ligation may have dis-
rupted flow to this and possibly similar vessels and
caused myocardial injury. Bypass grafting distal to the
aneurysm, in the absence of significant arterial stenosis
and without ligation, does not prevent the risks of rup-
ture or embolization. However, in the presence of poorly
defined distal anatomy preoperatively, additional distal
bypass is indicated.
End-to-end native artery anastomosis is not always
possible, particularly for patients with large aneurysms.
Dilatation of the heart in the near term after weaning
from cardiopulmonary bypass or long-term secondary to
underlying cardiac disease may promote catastrophic
anastomotic failure, suture line tension, and aneurysmal
recurrence.
Fig 3. Intraoperative view of aneurysm after marsupialization and
placement of reversed saphenous interposition vein graft. Box illus-
trates a close-up view.
Ann Thorac Surg
2000;70:1397– 8
Fig 4. Postoperative angiography demonstrates a patent interposi-
tion graft with a branching vessel just distal to the anastomotic
site.
Although percutaneous coil embolization or coated
stent placement does not require an open-chest surgical
procedure [5, 6], it risks arterial thrombosis, distal embo-
lization, or compromised coronary flow. Transcatheter
stents suffer from long-term patency concerns and pre-
dispose to premature graft stenosis, leading to repeat
coronary interventions. These risks should severely limit
these procedures to those patients who cannot undergo
the operation.
In conclusion, the physiologic advantages of reestablish-
ing normal anatomy with an interposition vein graft makes
this technique a superior alternative to other therapies.
Supported in part by grant 93–13880 from the American Heart
Association, Greenfield, TX, grant 1R01HL56688, National Heart,
Lung, and Blood Institute, Bethesda, MD, and grant NCC9 – 60,
National Aeronautics and Space Administration, Houston, TX.
References
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3. Harandi S, Johnston SB, Wood RE, Roberts WC. Operative
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tion 1998;82:1307– 8.
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