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.     

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.     

Coronary artery bypass grafting in adult coronary artery disease due to suspected Kawasaki disease in childhood

Development of coronary artery aneurysms is one typical complication of Kawasaki disease and can cause coronary artery disease even in early childhood. Information about course and outcome in adults is rare. Here, we present a 49-year-old man with serious three-vessel coronary artery disease and giant coronary artery aneurysms following suspected Kawasaki disease.     

Symptomatic coronary obstruction due to Kawasaki disease in an adult

Kawasaki disease is the most common cause of pediatric ischemic heart disease in the world, but it is unusual in adults. We present a case of Kawasaki disease in a young adult. This 20-year-old man presented with angina. Coronary angiography revealed aneurysmal obstructive lesions consistent with remote Kawasaki disease. The patient underwent coronary artery bypass grafting with arterial conduits. Postoperative echocardiography was normal and stress myocardial perfusion imaging showed no ischemia. He remained asymptomatic 12 months after surgery. There is controversy regarding optimal therapy, choice of conduit, treatment of proximal aneurysms, and surveillance in adults with Kawasaki disease.     

Pregnancy and Kawasaki disease

The management of a pregnant mother at 20 weeks' gestation presenting with ventricular fibrillation and her subsequent elective caesarean section at 38 weeks' gestation are described. Investigation showed the presence of coronary artery aneurysms due to Kawasaki disease. The pregnancy was further complicated by placenta praevia (grade IV).     

Coronary artery bypass grafting in an adult case with Kawasaki disease.

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease has been rarely reported in adult patients. We reported an adult case with few coronary risk factors but with multiple coronary artery aneurysms and obstructive lesions presumably secondary to Kawasaki disease who underwent coronary artery bypass grafting (CABG) with multiple arterial grafts. The postoperative course was uneventful. Because coronary artery sequelae of Kawasaki disease can be a cause of ischemic heart disease even in adults, heightened awareness of this possibility is required for young adults with coronary lesions but without coronary risk factors.     

Ischemic small bowel strictures in a case of incomplete Kawasaki disease

The authors describe an atypical case of Kawasaki disease in a 9-month-old girl who presented with fever, coronary artery aneurysms, and acquired ischemic stricture of the proximal jejunum. Histology of the surgical specimen was consistent with mesenteric vasculitis. The infant had only some of the typical clinical signs of Kawasaki disease, suggesting that an atypical or incomplete form of the disease was present. To the best of the authors' knowledge this is only the third case to be reported of incomplete Kawasaki disease associated with ischemic bowel stricture. J Pediatr Surg 36:648-650.     

Presumed Kawasaki disease resulting in multiple coronary artery aneurysms in an adult

Kawasaki disease (mucocutaneous lymph node syndrome) is a pathological process seen mostly in children, but has been reported in adults. The late manifestations of the syndrome can include the development of multiple coronary artery aneurysms. This article describes a 27-year-old man with no risk factors for atherosclerotic disease with multiple coronary artery aneurysms.     

Popliteal aneurysm presenting as acute thrombosis and ischemia in a middle-aged man with a history of Kawasaki disease

Kawasaki disease is known to cause a vasculitis of small and medium-sized vessels, with subsequent aneurysm formation. Most of the severe manifestations of the disease occur as a result of coronary aneurysm formation. However, many other arteries have been documented to be involved. A case is presented of a middle-aged man with a history of Kawasaki disease who had an acute ischemic limb from a thrombosed popliteal aneurysm that formed as a result of the disease. This is the first known case report of Kawasaki disease resulting in delayed lower extremity ischemia. Typical findings of patients with Kawasaki disease are presented, along with a case report and review of the literature. A history of Kawasaki disease is an extremely rare but possible cause of peripheral aneurysms, even in middle-aged patients. (J Vasc Surg 1997;26:884-7.)     

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.     

Surgical presentation of Kawasaki disease (mucocutaneous lymph node syndrome)

Five patients with Kawasaki disease (mucocutaneous lymph node syndrome) are reported whose varied presentations included acute abdominal pain, peripheral arterial aneurysms, digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo-obstruction. As the complications of the disease can usually be managed without resort to surgery, which is associated with a mortality rate of up to 25 per cent, the recognition of Kawasaki disease will prevent hazardous and unnecessary laparotomy.     

Peripheral gangrene associated with Kawasaki disease and successful management using prostacycline analogue: a case report

We report a case of child-onset Kawasaki disease that presented as a prolonged fever and manifested with coronary aneurysms and peripheral gangrene of the lower limbs. Therapy with intravenous immunoglobulins, corticosteroids, aspirin, anticoagulants, and ilomedine, a prostacyclin analogue, resulted in rapid improvement in the patient's condition without extremity loss. Those treating patients with Kawasaki disease must be aware of possible vascular ischemia in the disease process that is reversible by early intervention treatments, including the use of a prostacycline analogue, that improve quality of life.     

Recognition and operative management of patients with arteriosclerotic coronary artery aneurysms.

Arteriosclerotic aneurysms of the coronary arteries have been noted in 38 patients undergoing cardiac surgical procedures. Age, sex, and risk factors are similar to those in other patients with coronary artery disease. A high incidence of previous myocardial infarction (24 of 38) is related to the frequency of clot formation and embolism associated with such aneurysms. There is also an increased risk of perioperative infarction following coronary artery bypass grafting if the suture line involves the aneurysm wall (6 of 6), but not when sutures are placed away from it. The importance of recognition and proper operative management is stressed.     

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.     

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: a case report and review of the literature

BACKGROUND

Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction.

CASE DESCRIPTION

A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2.

CONCLUSION

This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.     

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.     

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.     

Moyamoya disease with intraventricular hemorrhage due to rupture of lateral posterior choroidal artery aneurysm: case report

Intracranial aneurysms associated with moyamoya disease are often reviewed. Aneurysms not around the circle of Willis but on the collateral vessels are rare. A 71-year-old woman presented with sudden onset of severe headache and vomiting. CT scan showed an intraventricular hemorrhage from bilateral lateral ventricle to fourth ventricle. Cerebral angiography showed the occlusion of the terminal portion of the bilateral internal carotid artery with moyamoya vessels and three aneurysms at the distal portion of the left lateral posterior choroidal artery. Clinical symptoms improved day by day, but 17 days later, due to rebleeding of the aneurysms the patient fell into coma. The day after rebleeding, endovascular embolization was performed using liquid particle, and the left lateral posterior choroidal artery and the aneurysm were occluded. Brain infarction with massive brain edema of the left cerebral hemisphere resulted in the patient's death. The management of the aneurysms in the basal ganglia and on the collateral vessels associated with moyamoya disease is controversial. We suggest positive intervention during the acute stage for the peripheral artery aneurysms taking endovascular embolization into consideration to prevent rupture or rebleeding.     

Atypical Kawasaki disease: A patient with coronary,brain, and internal mammary arteritis

Here we report a rare case of atypical Kawasaki disease (KD) in a patient presenting with systemic arteritis affecting the coronary arteries, brain, and internal mammary arteries (IMAs). A 25‐year‐old man was referred to our institute with angina pectoris. Coronary angiography revealed coronary artery aneurysms and triple‐vessel disease. Three‐dimensional brain computed tomography showed multiple small saccular aneurysms on the vertebral and posterior inferior cerebellar arteries. Off‐pump coronary artery bypass (OPCAB) grafting ??????was performed; however, the bilateral IMAs were tightly adhered and not patent. OPCAB was completed using the bilateral radial and gastroepiploic arteries. This is the first report of KD involving the IMA.