A 18-year-old girl, a university student, who developed aneurysms of 3 cm in diameter at very proximal sites of right and left coronary arteries. There is no stenotic lesion in the coronary systems. There is a slight ischemic area at the inferior wall without any symptoms. She is doing a normal daily life, but any sport activities are prohibited. I would like to operate on her to prevent aneurysm rupture and thromboembolism from the aneurysms, and also to return her to active life. What do you think about indications for operation, and how to operate?
My own personal experience in Kawasaki disease is one patient 13 years old boy with aneurysmal LM (~3.2cm). We did total arterial revsacularization of the left system with aneursmectomy "LM was full of thrombi". Patient did well and discharged after one week. In his annual follow up there were stenses of the grafts (20-50%). We dicided to follow up medically but the patient will require reoperation later. The patient had IV globulin pre-operatively.
I think the indications of surgery in Kawasaki can be broadly divided into surgery for stenotic or aneurysmal lesions. Stenotic lesions will not differ from that of adult atheroscelortic lesions. In aneursymal lesions "we need to know the diamters at which intervension is indicated.
I agrre with your surgical strategy. At amoment, I am planning to graft the LAD and the LCx with bilateral ITAs and interpose the proximal site of RCA with a short piece of SVG.
I agree with your surgical strategy because the aim of the intervention should be the prevention of embolism from the aneurysmal sites to distal coronary arteries.
What do you think about anticogulation treatment in association to aspirin or/and other antiplatelets drugs in the postoperative follow up? I use this care in patients with aneurysm of coronary arteries.
Thank you very much for your response. As for anticoagulation, we would use warfarin for 3 months in addition to aspirin, because we have to use a piece of SVG for reconstruction of the proximal RCA. After several months, only aspirin should be enough.
Aneurysms may get thrombosed and occluded. Moreover, when particularly large, there is risk of rupture (quite rare however).
Small aneurysms may be treated with Aspirin and Warfarin and followed up.
When there is risk of rupture or occlusion (intaluminal thrombosis) a surgical treatment may be indicated. Aneurysms should be excluded and bypass graft performed. Personally I prefer not opening the aneurysms, but ligating it from outside, to avoid coronary embolization. For the same reason I prefer administering retrograde cardioplegia, venting any embolus from the ascending aorta. This is particularly true when thrombi are still fresh.
Thank you very much for your comments. I actually performed an operation for the patient. I put RITA to the proximal LAD, LITA to the proximal LCx, and SVG to the RCA just distal to the aneurysm. I opened the aneurysms and closed the inflow and outflow orifices from the inside of the aneurysms. The patient went well. As you suggested, ligation of the inflow and outflow from the outside may be another option; however, it is sometimes difficult, especially when an aneurysm is very large and the aneurysm is located at the orifice of the coronary system.
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