712 CASE REPORT WESTABY ET AL Ann Thorac Surg TRAUMATIC CORONARY ANEURYSM 1995;60:712-3
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Posttraumatic Coronary Artery Aneurysm Stephen Westaby, FRCS, George Drossos, MD, and Nicholas Giannopoulos, MD
Oxford Heart Centre, Oxford, England
A 31-year-old man sustained blunt deceleration trauma with dissection of the left anterior descending coronary artery. We repaired a posttraumatic coronary aneurysm to prevent late occlusion of the recanalized vessel. An internal mammary artery graft was applied as a precau- tion against postoperative thrombosis. Follow-up at 12 months showed improved left ventricular function.
(Ann Thorac Surg 1995;60:712-3)
D espite the frequency of deceleration blunt chest trauma, coronary artery injuries are rare. Posttrau- matic left anterior descending coronary aneurysm has been described previously in association with acute myo- cardial infarction and left ventricular aneurysm [1-3]. Traumatic coronary artery occlusion and rupture also occur without aneurysm formation [4, 5]. Because of the unusual nature of this injury there is little consensus as to optimum management. Some authors suggest a wait and watch option, whereas others have advocated operation [2, 3]. In 1 case a left ventricular aneurysm was resected and coronary aneurysm left in situ due to "'inaccessibil- ity" . In this report we describe a patient who sus- tained blunt cardiac trauma with acute dissection of the left anterior descending coronary artery and myocardial infarction. We elected to repair the aneurysm to avoid the
possibility of secondary thrombosis of the recanalized artery.
A 31-year-old man sustained multiple injuries during a motorcycle accident. Skeletal trauma included bilateral fractures of the humerus and fracture of the right tibia and fibula. In addition he sustained a head injury with cerebral contusion and subarachnoid hemorrhage, which resulted in unconsciousness for 24 hours. On the 12th postoperative day he complained of retrosternal chest pain and became dyspneic with chest roentgenographic findings of pulmonary edema. The electrocardiogram suggested acute anterior myocardial infarction. Two- dimensional echocardiography showed apical and ventric- ular septal dyskinesia. He required intermittent positive- pressure ventilation and intravenous nitrate therapy for 4 days, after which he made an uneventful recovery.
Four weeks later and 2 months after the accident he underwent coronary angiography. This showed a dis- crete proximal left anterior descending coronary artery aneurysm with a patent distal artery (Fig 1). Left ven- triculography showed dyskinesia of the interventricular septum and left ventricular apex, but a substantial area of left anterior descending territory remained viable. He was referred for operation.
Median sternotorny was performed and the left inter- nal mammary artery harvested. Inspection of the heart showed thickening and fibrosis of the traumatized right ventricle and scarring in the area of anterior myocardial infarction. The left anterior descending coronary artery was patent, and there was no mitral or tricuspid regur- gitation. Palpation of the proximal left anterior descend- ing coronary artery behind the pulmonary artery re- vealed the site of the coronary aneurysm. We decided to approach this directly by transection and anterior retrac- tion of the main pulmonary artery.
The heart was arrested with anterograde St. Thomas"
Accepted for publication March 21, 1995
Address reprint requests to Mr Westaby, Oxford Heart Centre, Oxford Radcliffe Hospital, The John Radcliffe, Oxford, England OX3 9DU.
Fig 1. Coronary angiogram showing the left coronary artery with a traumatic aneurysm at the origin of the left anterior descending cor- onary artery.
1995 by The Society of Thoracic Surgeons 0003-4975]95/$9.50 0003-4975(95)00342-I
Ann Thorac Surg CASE REPORT WESTABY ET AL 713 1995;60:712-3 TRAUMATIC CORONARY ANEURYSM
cardioplegia, and the pulmonary artery was transected, providing direct access to the left main and proximal left anterior descending coronary arteries. The aneurysm was opened longitudinally; the morphology of this was compatible with acute localized dissection of the vessel wall. The aneurysm was obliterated by continuous su- ture, and the left internal mammary artery was anasto- mosed to the middle third of the left anterior descending artery. The procedure was performed with normothermic perfusion and cardiopulmonary bypass, which was dis- continued without difficulty. He was extubated immedi- ately and discharged from the hospital on the sixth postoperative day. At follow-up 12 months later he is asyrnptomatic (New York Heart Association functional class I) with a normal exercise electrocardiogram and improvement in echocardiographic contractile function of the interventricular septum. We could not justify repeat angiograms.
Saccular aneurysms occur in both Kawasaki's disease and atheromatous coronary disease and may thrombose with embolization or occlusion of the parent vessel. Aneurysms also occur after percutaneous transluminal coronary angioplasty, and the incidence of this problem may increase in the future. Coronary aneurysms are extremely rare after blunt chest trauma and are usually associated with acute myocardial infarction through tem- porary occlusion of the injured vessel. Bjorn-Hansen and colleagues I2] documented the natural history of one posttraumatic aneurysm with angiography 1, 5, and 11 months after the accident. Their patient remained asymptomatic and the aneurysm disappeared, presum- ably by thrombosis of the lumen. Stone and Fleming I3l described a 17-year-old patient with a proximal left anterior descending coronary artery aneurysm almost identical to that in our own patient but with a well- established left ventricular aneurysm. The left anterior descending vessel was widely patent. In their patient left ventricular aneurysmectomy was performed but the cor- onary aneurysm was left in situ because of inaccessibility. In the presence of an established aneurysm further left anterior descending coronary artery occlusion did not pose a threat, but the patient suffered a stroke postoper- atively.
Our patient had viable muscle in the left anterior descending coronary artery territory and, although there is nothing in the l iterature to suggest that this aneurysm was likely to rupture, the possibil ity of thrombosis with propagation into the left anterior descending coronary artery lumen remained. We made a direct surgical ap- proach to the distal left main coronary artery and proxi- mal left anterior descending coronary artery and opened the aneurysm directly. Access to the left main and prox- imal left anterior descending coronary arteries is straight- forward when the pulmonary artery is transected. Al- though the left main coronary artery can be approached by retraction on the pulmonary artery in the empty heart, there were inflammatory adhesions around the aneu- rysm, and transection of the pulmonary artery facilitated access. The morphology in our patient was clearly dis- section of the vessel wall with dilatation of the false lumen. There may well have been a risk of aneurysm rupture in this patient. Although the left anterior de- scending coronary artery remained patent after the re- pair, we decided to implant the left internal mammary artery on the distal vessel as an insurance policy. An alternative approach would have been to excise the aneurysm and close the vessel with a vein patch, but we did not consider this to be as reliable as an internal mammary graft.
Despite advocates of conservative treatment we advise direct surgical repair of posttraumatic coronary aneu- rysm to prevent the potential for late thrombosis with occlusion of the distal vessels.
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