Discussion
A
case with complete calcified coronary artery aneurysms involving both
the right coronary artery and the left anterior descending artery is
rare. Most coronary artery aneurysms
involve only one artery, and less than 25% of cases involve multiple
arteries [3, 4]. CAAs with an artery diameter
greater than 20 mm or four times the normal reference artery diameter
was defined as giant coronary artery aneurysms[5,
6]. In this case, the dimension of the CAA can reach
2.5cm×1.6cm×2.0cm, and 1.4cm×1.3cm×2.0cm respectively, which can be
classified as a giant coronary artery aneurysm involving bilateral
coronary artery.
The
most common cause of coronary artery aneurysms is atherosclerosis, and
other causes including congenital heart disease, Kawasaki disease,
Marfan syndrome, Ehlers-Danlos syndrome, Takayasu arteritis, nodular
arteritis, and syphilitic aortitis, Scleroderma, systemic lupus
erythematosus, Behçet’s disease, fibromuscular dysplasia and iatrogenic
injury[5, 7-9]. The patient did not have a history
of atherosclerosis, connective tissue disease, or interventional
therapy. To our knowledge, there are three reports that are very similar
to the clinical evolution and imaging manifestations of this case[10-12]. The causes of CAA did not seem to be
clear, and maybe relate to the ambiguous history of Kawasaki disease in
childhood without standardized treatment. It has been reported that 5/22
of cases with Kawasaki disease occurred calcification during
follow-up. In addition, the report
also proposed that the diameter of the aneurysm in the case with
calcification is larger than that in the case without calcification[13]. Kaichi and colleagues pointed out that the
risk of CAA in the longterm calcification (20 years) was as high as 94%
for patients with Kawasaki disease without symptoms but with a
CAA> 6 mm [11]. Therefore, for
patients without symptoms in childhood and with CAAs calcification in
adulthood, are more likely to have Kawasaki disease in childhood, and
this kind of disease can be used as a risk stratification factor for
long-term sudden death in patients with Kawasaki disease[14].
According to the literatures, most
coronary aneurysms are asymptomatic, some patients suffered from angina,
myocardial infarction, sudden death, congestive heart failure,
etc[5, 15]. In addition, the majority gender of
cases are male, which is similar to the aggregated data of Morita,
Keyser, Ino and Li, and these data suggest that CAAs may be more common
in male patients. [3, 4, 16, 17].
There are no an effective treatment
for CAA, and further studies are needed to establish a guideline. Due to
the risk of thrombosis associated with CAA, platelet inhibitors are used
to prevent ischemic synthesis caused by fibrin thrombosis and
microemboli, so antiplatelet and/or anticoagulation therapy were
recommended [5, 18].
Surgical treatment was an option to
avoid CAA rupture, dissection, myocardial ischemia and embolism[2, 19, 20], although their specific surgical
treatment standards have not yet reached consensus[1]. For CAAs, multiple surgical strategies have
been reported, including reconstruction, resection or exclusion, as well
as ligation combined with coronary artery bypass, patch, or hybrid
repair[21-25].
Especially for patients with normal distal vessels, coronary artery
bypass grafting is the preferred treatment [1, 2].
According to the summary of all cases with CAA calcification and
stenosis [2, 10, 12, 13, 22, 26-38] (Table 1),
surgical treatment based on CABG can effectively solve the problem of
CAA calcification and stenosis. Unfortunately, all reports have no
long-term follow-up results.
The long-term patency rate of internal mammary artery bypass for
coronary aneurysms is much higher than that of great saphenous vein
bypass (77.1%±1.1%compared to 46.2%±6.3% for patency 85 months after
operation) [1, 39]. There are few reports on the
internal mammary artery + radial artery in treatment of stenotic and
calcified CAA.
To summarize, we reported a case of a coronary artery aneurysm with
calcification and stenosis involving two coronary arteries, and
underwent a
complete
arterialized bypass operation, with a good result. By reviewing the
literature, the morbidity of CAAs in male patients seem to be more
higher than it in female patients. Kawasaki disease is likely to be a
causative factor in some patients with asymptomatic CAA involving
calcification and stenosis. And CABG is a feasible treatment option for
coronary artery aneurysms with calcification and stenosis.