Myocardial revascularization using bilateral internal mammary arteries for total occlusion of LMCA in an adult case: sequelae of Kawasaki's disease in childhood

A 43-year-old female patient suffering from effort angina underwent coronary artery bypass grafting. Coronary arteriogram demonstrated complete occlusion of the left main, proximal circumflex (Cx), and proximal left anterior descending coronary arteries (LAD) and a nonocclusive fusiform calcified aneurysm of the proximal right coronary artery (RCA). The left coronary artery system opacified via collateral vessels from the RCA. No other abnormalities were found in the entire aorta and its major branches. Myocardial revascularization was performed using the right IMA to bypass to the Cx and the left IMA to bypass to the LAD successfully. Prior to the operation, she had neither coronary risk factors nor inflammatory signs, though she had experienced fever of unknown origin lasting about a week when she was 11 years old. Accordingly we supposed that such coronary arterial lesions might have arisen from Kawasaki's disease in her childhood.     

Surgical treatment in an adult with coronary artery aneurysm at proximal site of left anterior descending artery; report of a case

A 52-year-old man was admitted to our hospital with complaint of chest pain and abnormal electrocardiogram (ECG) findings showing ST depression in V2-V6. Coronary computed tomography (CT) and coronary arteriography (CAG) showed coronary artery aneurysm at #5 [left main trunk (LMT)] 20 mm, #11 [circumflex artery (Cx)] 8.3 mm, RV branch 4 mm, and severe stenosis at #5 and #11. Therefore, his chest pain was due to thromboembolism from coronary artery aneurysm. In the present case, Kawasaki disease was not diagnosed in childhood. Coronary artery aneurysms were rare in the elderly and were usually found in association with Kawasaki disease. Morphological evaluation findings strongly suggested that the coronary artery aneurysm were related to Kawasaki disease. Resection of coronary artery aneurysm and coronary artery bypass grafting [left internal thoracic artery (LITA) to #8 and saphenous vein graft (SVG): aorta (Ao) to #14] were successfully performed. We report a case of coronary artery aneurysms presumed to be due to childhood Kawasaki disease in an elderly man.     

Treatment of a giant coronary artery aneurysm in an adult with a history of Kawasaki disease by resection and bypass grafting: Report of a case

We report herein the case of a 22-year-old man with a history of Kawasaki disease who developed a giant calcified aneurysm of the left main coronary artery. The aneurysm was successfully resected and coronary bypass surgery was performed using the bilateral internal thoracic arteries. The resected aneurysm, the maximal diameter of which was 27 mm, showed heavy calcification of the inner layer and extended into the adjacent coronary arteries, producing a significant narrowing of the lumen of both the left main trunk (50%) and the anterior descending branch (50%). Extensive intimal calcification presumably prevented normal luminal development and produced a significant narrowing as the patient grew into adulthood. A cause for stenotic lesions developing in the coronary artery adjacent to a coronary aneurysm in adults with a history of Kawasaki disease is suggested here by the resected aneurysm seen in this patient. Thus, adult patients with giant coronary artery aneurysms and significant stenotic lesions of the coronary artery associated with Kawasaki disease may require aneurysmectomy in addition to bypass surgery.     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

Rupture of a giant coronary artery aneurysm due to Kawasaki disease

Coronary artery aneurysm requiring surgery is rare. We report a case of a ruptured giant coronary artery aneurysm due to Kawasaki vasculitis which presented with cardiac arrest and was successfully treated by emergency coronary artery bypass grafting. The controversies surrounding the management of this disease are also discussed.     

Coronary artery bypass grafting for coronary aneurysms due to Kawasaki disease.

We report a 23-year-old man who underwent coronary artery bypass grafting (CABG) for coronary aneurysms associated with Kawasaki disease using the left internal thoracic artery (LITA) and right gastroepiploic artery (RGEA) after a second myocardial infarction (MI). Preoperatively, this patient showed repetitive occlusion and recanalization of coronary artery flow without coronary stenosis. Indication of bypass surgery in Kawasaki disease is usually associated with stenosis. However, even an aneurysm alone should be an indication of surgery if there is any kind of ischemic event.     

Coronary bypass surgery in kawasaki disease in a four-year-old patient: case report

Kawasaki disease is an acute vasculitis syndrome of unknown etiology that mainly affects small and medium-sized arteries, particularly the coronary arteries. This disease is rarely seen in infants and young people in Turkey. In this short report, we present a four-year-old patient who has Kawasaki disease associated with coronary artery aneurysm and underwent coronary bypass grafting.     

Coronary artery disease in aortic surgery

The incidence of coronary artery disease in patients coming to aortic surgery and the impact of aggressive preoperative cardiac catheterization and myocardial revascularization was prospectively analyzed in 59 patients. Seventy-five percent of patients had at least one-vessel involvement, and 32% had three-vessel or left main involvement. Patients with electrocardiographic evidence of coronary artery disease had at least one-vessel involvement 84% of the time and three-vessel, left main involvement 36% of the time. Sixty-four percent of patients with no preoperative indications of coronary artery disease had at least one-vessel involvement and 29% had three-vessel, left main involvement. Resting (39 patients) and exercise multiple-gated acquisition scans (22 patients) did not predict the presence of coronary artery disease in patients without a history or electrocardiographic evidence of coronary artery disease. Myocardial revascularization was performed prior to aortic surgery in 17 patients (29%). The operative mortality was 3.7% with two patients dying from noncardiac-related complications. There were two additional deaths prior to aortic surgery with one patient dying during coronary artery bypass grafting, and one dying of aneurysm rupture prior to repair, making the overall mortality associated with this approach 7.4%. Preoperative cardiac catheterization and an aggressive approach toward coronary artery bypass grafting reduces the risk of cardiac complications in aortic surgery.     

Review: surgical treatment of giant coronary aneurysms in pediatric patients with Kawasaki disease

In Kawasaki disease (KD), giant coronary aneurysms in the proximal segments of the coronary arteries have long been among the serious complications associated with acute myocardial infarction. To treat myocardial ischemia in children, Kitamura et al. first performed coronary artery bypass grafting in a pediatric patient using an autologous saphenous vein. In the early 1980s, they began to use the internal thoracic artery (ITA) as a bypass graft to the left anterior descending artery, which later was proven to improve long-term life expectancy with its favorable long-term patency, as well as growth potential. Thus, the excellent characteristics of the ITA have come to be widely known among pediatric cardiac surgeons, and a growing number of coronary bypass surgery procedures using the ITA are now being performed worldwide. Although a longer follow-up with more patients is necessary, downsizing reconstructive procedure may be a treatment of choice for giant aneurysms of non-LAD territories to improve coronary circulation. The efficacy of surgical treatment for giant coronary aneurysms in pediatric patients with Kawasaki disease is now well established. Pediatric coronary artery bypass grafting using the ITA, either single or bilateral, can be safe not only for patients with Kawasaki coronary disease but also for infants with congenital coronary lesions.     

Thoracic endovascular aortic repair and off-pump coronary artery bypass grafting after renal transplantation: a case report

Twelve years after receiving a renal transplant, a 50-year-old woman developed asthmatic symptoms. Chest CT revealed a descending thoracic aortic aneurysm. She had undergone percutaneous coronary intervention to treat the left anterior descending artery 10 years earlier. Coronary artery angiography revealed restenosis of the left anterior descending artery (99%, #6 in-stent). Because cardiopulmonary bypass may cause problems for transplanted kidney, we performed off-pump coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery) and thoracic endovascular graft placement to treat the aortic aneurysm. Considering that the artery of the transplanted kidney was attached to the right iliac artery, and then the left common femoral artery was selected as the access root for GORE TAG(?) endografts (34 × 200 and 34 × 150 mm) (stentgrafts were deployed for the descending aortic artery). Postoperative angiography showed a patent bypass graft. Postoperative CT confirmed the absence of endoleaks. The postoperative course was uneventful, and she was discharged without complications. Ischemic heart disease and descending thoracic aortic aneurysm in recipients of kidney transplants can be treated using off-pump coronary bypass grafting and thoracic endovascular graft placement. The transplanted kidney was protected without using cardiopulmonary bypass (CPB).     

Severe Kawasaki heart disease treated with an internal mammary artery graft in pediatric patients. A first successful report

Two Japanese boys, 6 and 10 years old, required operation for severe Kawasaki heart disease. Both had multiple coronary arterial aneurysms and stenoses, and one had mitral regurgitation as well. The operations consisted of anastomosis between the left internal mammary artery and the left anterior descending artery and insertion of an autologous saphenous vein between the aorta and the posterior descending artery in both patients. The mitral valve was replaced in the one with mitral regurgitation. Angina pectoris has been completely relieved as confirmed by postoperative angiocardiography. Late results of coronary bypass grafting with the saphenous vein in pediatric patients with Kawasaki disease have been less than satisfactory because of the high occlusion rate of the graft. The internal mammary artery may be superior, at least theoretically, to the saphenous vein graft because it is a "living graft" with a high possibility of growing and with less susceptibility to degeneration. This is the first report of successful operation utilizing an internal mammary artery graft in coronary bypass for Kawasaki disease.     

Two cases of off-pump coronary artery bypass grafting combined with abdominal aortic aneurysm repair.

Two cases of coronary artery disease coexisting with abdominal aortic aneurysm were treated with off-pump coronary artery bypass grafting combined with repair of the aneurysm. The first patient was a 67-year-old man exhibiting a large pulsating abdominal mass. Abdominal computed tomography demonstrated a 9-cm aneurysm and coronary angiogram revealed a 90% stenosis of the obtuse marginal branch for which percutaneous transluminal angioplasty could not be performed. He underwent simultaneous single coronary artery bypass grafting without cardiopulmonary bypass, and bifurcated graft replacement. The second patient was a 71-year-old man who had acute myocardial infarction, and one month later underwent coronary angiogram which revealed three vessel disease in the coronary artery. Computed tomography revealed a 4-cm aneurysm, and angiography showed a 90% stenosis of the left renal artery. He underwent a single stage operation that involved three coronary artery bypass grafting without cardiopulmonary bypass, straight graft replacement, and reconstruction of the left renal artery using the saphenous vein graft. The postoperative course was uneventful in both cases. We currently recommend a single stage operation involving off-pump coronary artery bypass grafting.     

Successful repair for a giant coronary artery aneurysm with coronary arteriovenous fistula complicated by both right- and left-sided infective endocarditis

We report a rare case of a 65-year-old woman who underwent an emergent lifesaving heart operation for an undiagnosed right coronary artery aneurysm with a coronary arteriovenous fistula complicated by active infective endocarditis, which affected the aortic valve, mitral valve, and coronary sinus. We performed direct closure of the coronary arteriovenous fistula, ligation of the right coronary artery aneurysm, double coronary artery bypass grafting, and double valvular replacement. Five years after the operation, she had no sign of congestive heart failure or infection, and was not receiving antibiotics.     

Surgical experience with coronary arterial sequelae of Kawasaki disease in children

The coronary arterial sequelae due to Kawasaki disease have been treated surgically in five children ranged from 6 to 9 years old. The procedures were aortocoronary bypass surgery in all cases, coronary artery aneurysmectomy in one case and left ventricular aneurysmectomy in one case. The early results of operated cases have been good with the graft patency of 86% confirmed by angiography one month after surgery. The characteristic features of coronary artery damage in patients with Kawasaki disease are coronary artery aneurysms, which manifest wall irregularity, thrombus, calcification and stenosis. The significant stenosis of coronary artery could often be observed at the inlet or outlet of the aneurysm in major coronary artery branches. Although the early results of aortocoronary bypass surgery in the children with Kawasaki disease have been good, long-term follow up is mandatory to investigate the status of autogenous saphenous vein grafted in children.     

Natural evolution of coronary artery ectasia after coronary artery bypass grafting

Coronary artery aneurysm and ectasia, unusual angiographic findings, are considered as variant of atherosclerotic coronary artery disease. A 49-year-old man whose right coronary artery ectasia had progressed to large aneurysm, accompanied by advanced obstructive coronary artery disease, 6 years after the initial coronary artery bypass grafting. It was treated with ligation of aneurysm and distal bypass grafting under cardiopulmonary bypass. Fragile fresh clot was formed within the aneurysm irrespective of coumadin therapy as a standard regimen for the coronary artery ectasias. We will discuss the surgical management for the dilated coronary artery with significant coronary stenosis.     

Endovascular stent-grafting via the aortic arch for distal arch aneurysm: An alternative of endovascular stent-grafting in a complicated case.

A 67-year-old man with severe discomfort was diagnosed with a rupture of the thoraco-abdominal aneurysm, a distal arch aneurysm and triple coronary artery disease. After emergency surgery for a thoracoabdominal aneurysm, a scheduled surgery for coronary artery bypass grafting and endoluminal stent-grafting for the distal arch aneurysm was performed simultaneously. A stent-graft was introduced into the descending aorta via a small incision on the arch aorta. Open endovascular stent-grafting via the arch aorta is an alternative for repairing a distal arch aneurysm with coronary artery bypass grafting.     

Coronary artery bypass grafting in a case with severe aortic atheromatosis associated with abdominal aortic aneurysm.

A 69-year-old man with coronary artery disease associated with abdominal aortic aneurysm underwent a one-stage operation utilizing a low-flow cardiopulmonary bypass. Ordinary cardiopulmonary bypass was abandoned as a result of severe atheromatous finding in the entire aorta. However, coronary artery bypass grafting without cardiopulmonary bypass was hazardous as a result of heart enlargement and deteriorating function. Therefore, the abdominal aortic aneurysm was first replaced with a bifurcated graft. Coronary artery bypass grafting with two arterial grafts was then performed successfully on the beating heart with the support of a low-flow cardiopulmonary bypass connected to the bifurcated graft.     

Reoperative coronary artery bypass via left thoracotomy.

The patient was a 49-year-old woman. When she was 39 years old, she underwent coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery, saphenous vein graft to first diagonal branch). At the age 48, she had effort angina. On coronary angiography, triple-vessel disease was found, and she was treated conservatively. Progression of the disease was confirmed with detection of the left circumflex artery associated with jeopardized collateral to the right coronary artery showing total occlusion. The patient underwent reoperation. Since the left internal thoracic artery was patent despite occlusion of the saphenous vein graft, the approach of left thoracotomy was employed. Under cardiopulmonary bypass with ventricular fibrillation and left vent through left atrial appendage, the right radial artery was anastomosed to the left circumflex artery from the descending thoracic aorta, and the right gastroepiploic artery was anastomosed to the right coronary artery (4AV branch). Patency of the bypass was confirmed postoperatively. We consider this operative technique was especially useful for reoperation in cases of a patent internal thoracic artery in which left thoracotomy can be conducted safely.     

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.     

Coronary bypass in an adult with Kawasaki disease

We present the case of a 30-year-old female patient with few coronary risk factors for atherosclerosis but with 3-vessel coronary artery disease possibly secondary to Kawasaki disease. Coronary angiography showed total occlusion of the left anterior descending artery and a right coronary artery aneurysm. Quadruple coronary artery bypass was performed. The postoperative course was uneventful.