Fistula occlusion and ligation for a giant right coronary artery aneurysm concurrent with right atrial fistula: a case report
Coronary artery aneurysms in most cases require surgical treatment once diagnosed. Lifelong anticoagulation is often needed after surgery. We herein describe a 55-year-old man who was asymptomatic and diagnosed with right giant coronary artery aneurysm combined with right atrial fistula.
This is a case of asymptomatic giant right coronary artery aneurysm concurrent with coronary artery fistula. Because the aneurysm was in the distal right posterior descending coronary artery, right coronary artery ligation and fistula occlusion through the right atrium were performed in the absence of cardiopulmonary bypass. The aneurysm was excluded without impacting the myocardial blood supply, and the patient was exempted from lifelong anticoagulation regimen. The follow-up revealed favorable outcomes and the patient’s life expectancy was improved.
Decompression and exclusion without cardiopulmonary bypass can be adopted for distal coronary artery aneurysms that do not involve or only have a limited impact on distal blood supply. This procedure can exempt the patient from the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy to perform.
KeywordsCoronary artery aneurysm Coronary artery fistula Cardiopulmonary bypass
Acute marginal branch
Atrial septal defect
Coronary artery aneurysms
S′ velocity of Doppler tissue imaging
Left anterior descending coronary artery
Left ventricle ejection fraction
Posterior descending coronary artery
Right coronary artery
Tricuspid Annular Plane Systolic Excursion
Coronary artery fistula (CAF) is a rare congenital anatomical anomaly with an incidence of about 0.2% [1, 2]. CAF is associated with aneurysms in 19% of the cases. Moreover, these aneurysms may fistulate to the right atrium with an incidence of 26% . An aneurysm > 20 mm in diameter is termed as a giant coronary aneurysm . Though the underlying mechanism remains unknown, it is believed that the increased blood flow and pressure destroy the media structure of the vascular wall and decrease the elasticity of the coronary artery, thereafter arousing the concurrent aneurysm. In adults, atherosclerosis is the most common cause for coronary artery aneurysm (CAA), which accounts for 50% of all the cases [5, 6]. CAA of all sizes may rupture and the risk of rupture increases in a size-dependent manner . Prompt surgery is necessary for patients with evident symptoms of CAA. Yet for asymptomatic patients, whether surgery is a necessity is controversial. Surgical treatment is recommended to asymptomatic patients due to the low natural closure rate of fistula and the potential complications of aneurysm like myocardial ischemia, bacterial endocarditis and coronary artery aneurysm. This paper reports a case of asymptomatic a giant right coronary artery aneurysm concurrent with coronary artery fistula. Surgery was performed in the absence of cardiopulmonary bypass (CPB) and the patient was exempted from a lifelong postoperative anticoagulation regimen.
Discussion and conclusion
Although conventional CAA surgery under CPB has some possible complications, including intraoperative ischemia, impaired hemostasis and mechanical trauma to blood cells [8, 9], many surgeons still believe it is the “gold-standard” operation for this type of pathology. In the present case, the surgery was performed in the absence of CPB procedure not only to avoid the CPB- associated complications , but also to monitor cardiac ischemia in “real-time” and facilitate repair.
In the present case, the giant CAA was formed at the distal right posterior descending coronary artery (PDA). Since PDA is connected to the left anterior descending coronary artery (LAD) through small branches, the fistula orifice in the aneurysm could “steal” blood from the posterior descending branch of the RCA. So, when myocardial ischemia occurs, the LAD might compensatorily extend and supply blood to this ischemic part. It explained why the patient had no symptoms of myocardial ischemia prior to the surgery. Typically, if the surgical treatment had not been applied, the patient would have been on a long-term antiplatelet therapy to avoid the development of thrombus in the enlarged coronary artery (CA) and CAA. However, long-term medication would inevitably bring negative impacts on the patient’s physical and mental health, which would then impair the patient’s quality of life. Furthermore, even if on medication, he would still face the risks of thrombosis in the aneurysm, myocardial ischemia, rupture of aneurysm or other life-threatening complications. Now since surgery was performed and the size of the aneurysm was reduced, the risks mentioned above have been significantly reduced. Compared with lifelong anticoagulation therapy, the three-month medication lasted for a fairly short period. So, we believe the patient’s life expectancy might be improved by the surgery.
Comparison of cardiac markers and natriuretic peptides
Post-operative day 1
Post-operative day 2
Post-operative day 5
Post-operative day 7
Discharge Post-operative day 9
In conclusion, decompression and exclusion can be adopted for distal CAA that does not involve or only has a limited impact on distal blood supply. This procedure can spare the patient the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy and the patient’s quality of life can be remarkably improved. Individualized fistula treatment should be designed based on the location of the fistula and the maximized benefits for the patient.
YR collected the data and wrote the initial draft of the manuscript. KL, LX and WQR performed the operation and collected the data. KL also contributed to analysis and interpretation of the data. YJL, PJ and CPG were involved in postoperative evaluation of the patient. All of the authors contributed to drafting and critically revising the paper and gave final approval of the version to be published.
This study received no financial support.
Ethics approval and consent to participate
Consent for publication
Written informed consent was obtained from the patient to publish this case report and the accompanying images.
The authors declare that they have no competing interests.
- 9.Magovern JA, Mack MJ, Landreneau RJ, et al. The minimally invasive approach reduces the morbidity of coronary artery bypass. Circulation. 1996;94(Suppl I):I–51.Google Scholar
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