|Year : 2012 | Volume
| Issue : 2 | Page : 69-70
Left main coronary artery aneurysm: A rare presentation
Monika Maheshwari1, Chandra Prakash Tanwar2, SR Mittal1
1 Department of Cardiology, Jawaharlal Nehru Medical College, Ajmer, India
2 Department of Medicine, Jawaharlal Nehru Medical College, Ajmer, India
|Date of Web Publication||1-Aug-2012|
Navin Niwas, 434/10, Bapu Nagar, Ajmer-305001, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Left main coronary artery aneurysm is an uncommon coronary anomaly. We describe herein a male whose coronary angiogram revealed left main coronary artery aneurysm. The purpose of the case report is to highlight the clinical picture, workup, and treatment options for such patients.
Keywords: Aneurysm, angiography, coronary disease
|How to cite this article:|
Maheshwari M, Tanwar CP, Mittal S R. Left main coronary artery aneurysm: A rare presentation. Heart Views 2012;13:69-70
| Introduction|| |
Aneurysms of the left main coronary artery (LMCA) are exceedingly rare clinical entities, encountered incidentally in approximately 0.1% of patients who undergo routine angiography.  The majority are atherosclerotic in origin. Other causes include trauma, connective tissue disorders, Kawasaki disease, vasculitis, congenital, mycotic, and idiopathic. The primary complication is myocardial ischemia or infarction, with rupture being rare.  We describe herein a 59-year-old male presenting with effort angina whose coronary angiogram revealed LMCA aneurysm.
| Case Report|| |
A 43-year-old obese, hypertensive man, presented in emergency department with acute onset of chest pain at rest that radiated to his jaw and left arm associated with profuse sweating. On examination his pulse was 96/minute, blood pressure 190/100 mmHg, respiratory rate-28/minute and temperature -98.4 F. Jugular venous pressure was normal. There was no cyanosis, clubbing, icterus, pallor, or lymphadenopathy. Routine biochemical, renal, and liver function tests were within normal limits. CPK-MB was raised with maximum values of 60U/L. Electrocardiogram showed ST segment depression of 2 mm in anterior precordial leads. Chest skiagram revealed cardiomegaly. Left ventricular apex and upper 1/3 rd of inter ventricular septum were hypokinetic on echocardiogram with left ventricular ejection fraction of 48%. Coronary angiography revealed a fusiform LMCA aneurysm originating at the distal segment 45.7 × 30.6 mm in size [Figure 1] and [Figure 2]. The patient was advised surgery but he refused and was conservatively managed with dual antiplatelets including aspirin 150 mg and clopidogrel 75 mg and anticoagulants.
|Figure 1: Left Coronary angiogram (RAO Caudal view) showing fusiform aneurysm of distal left main coronary artery|
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|Figure 2: Left Coronary angiogram (LAO Caudal view) showing aneurysm of distal segment left main coronary artery|
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| Discussion|| |
Coronary artery aneurysm is an uncommon disease defined as coronary dilatation that exceeds the diameter of adjacent normal segments or the diameter of the patient's largest coronary vessel by 1.5 times. Overall incidence is 0.15% to 4.9% of patients undergoing coronary angiography.  The aneurysm occur most often in the right coronary artery followed in frequency by the circumflex and anterior descending artery.  Aneurysm of the LMCA are extremely rare; in a study by TOPAZ et al. involving a series of 22,000 coronary angiograms, they were found in only 22 patients (an occurrence rate of 0.1%).  The etiology of these aneurysms is usually atherosclerotic in adults with a complex interplay between tissue metalloproteinases and the proteolysis of extracellular tissue proteins. Increased levels of the 5A allele of MMP3 and MMP9 serve as additional markers promoting this pathogenesis. Other causes include trauma, connective tissue disorder - Polyarteritis Nodosa, Systemic Lupus Erythramatosus, Ehler Danlos Syndrome, Behcet Disease, Scleroderma, Marfan's Syndrome), Kawasaki disease, vasculitis (Takayasu Arteritis), congenital, mycotic and idiopathic. A recent development is increased incidence of aneurysm in patients who have undergone coronary artery stenting both with drug eluting stents (DES) and bare metal stents. In DES it appears to be secondary to the hypersensitivity reaction to the DES polymer predisposing to this condition once the effect of the antiproliferative drugs has worn off. 
The management of LMCA aneurysm is not well established owing to the rarity and unpredictable natural history. However, these dilated sections of artery are not benign entities because they are subject to spasm, thrombosis and spontaneous dissection and can be a potential cause of myocardial infarction. Surgical management is appropriate in symptomatic patients who have evidence of emboli from the aneurysm to the distal coronary bed, leading to myocardial ischemia. Surgery is also indicated in cases of progressive LMCA enlargement as documented by serial angiographic measurement. The preferred approach for surgical correction of LMCA aneurysm entails proximal and distal end ligation of the aneurysm with bypass of the LAD by means of the left internal mammary artery. Placement of a saphenous vein graft to bypass the left circumflex may also be necessary to adequately perfuse the left ventricle.  Patients not managed surgically must nevertheless be monitored very closely and treated with antiplatelet and anticoagulation therapy to prevent thrombus formation within the aneurysm. It is required to follow-up these patients every 3 months.
| References|| |
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[Figure 1], [Figure 2]