Hybrid Treatment for a Distal Left Main Coronary Artery Aneurysm　― Coronary Artery Bypass Grafting and Surgical Ligation Followed by Intraoperative Covered Stent Implantation ―

A 77-year-old man on hemodialysis had undergone crossover stenting from the left main coronary artery (LMCA) to the left anterior descending artery (LAD) and concomitant stenting in the proximal left circumflex artery (LCx) 6 years previously. He had undergone an emergency percutaneous coronary intervention (PCI) with rotational atherectomy followed by drug-coated balloon angioplasty from the LMCA to the LCx 4 months previously. However, coronary angiography for recurrent angina pectoris showed a proximal LCx restenosis and a rapidly developed coronary artery aneurysm (CAA) in the distal LMCA (Figure A–C). Because of the size and shape of the aneurysm (12 mm; saccular type), a history of crossover stenting, and ostial LCx restenosis, surgical intervention with revascularization and CAA resection would be favorable; however, severe adhesions (composed of hematoma) and the presence of implanted stents made CAA resection difficult. Therefore, a hybrid treatment comprising surgical revascularization and covered stent implantation was performed. After coronary artery bypass grafting (CABG) with saphenous vein grafting to the mid-LCx (final flow 30 mL/min), proximal LCx ligation was performed (Figure D–F). After CABG with the left internal thoracic artery to the distal LAD (final flow 56 mL/min) for mid-LAD stenosis and the possibility of a future event in the LAD after implantation of the covered stent, a 3.5/19-mm GRAFTMASTER covered stent (Abbott Vascular, Chicago, IL, USA) completely sealed the CAA (Figure G–I).

Figure.

Coronary angiography of the (A,B) aneurysm, (D,E) after coronary artery bypass grafting and proximal left circumflex artery (LCx) ligation, and (G,H) covered stent implantation. (C,F,I) Schema of left main coronary artery bifurcation during each procedure. A-P, anteroposterior; CAU30, caudal view 30; LAD, left anterior descending artery; LAO50, left anterior oblique 50; RAO30, right anterior oblique 30; SVG-LCx, saphenous vein grafting to the mid-LCx.

Established treatments are lacking for CAAs involving LMCA bifurcation lesions. PCI with intentionally implanting a covered stent across the main branch and side branch fenestration may be an alternative, but its safety and efficacy remain unclear.¹ A hybrid approach for treating a distal LMCA aneurysm with intraoperative implantation of a covered stent, after CABG and ligation of the inflow artery (main branch) to the CAA, may be feasible in surgically challenging cases with resection for LMCA aneurysms.

Acknowledgments

None.

Reference

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