J Cardiol 2004 Nov; 44（5）: 201 – 205

Complete Proximal Occlusion of All
Three Main Coronary Arteries
Complicated With a Left Main
Coronary Aneurysm: A Case Report
Takatoshi

WAKEYAMA, MD

Hiroshi

OGAWA, MD

Akira

TAKAKI, MD

Takahiro

IWAMI, MD

Masayasu

KIMURA, MD

Takeo TANAKA, MD
Hitoshi

UCHINOUMI, MD

Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
A 68-year-old woman with recurrent chest pain was referred to our institution. Coronary angiography
showed 100% obstruction of the left main trunk, the proximal right coronary artery with good collaterals tothe left anterior descending artery and left circumflex artery along the conus artery. Emergency surgicalrevascularization was undertaken with two saphenous vein grafts. The saphenous vein grafts were placedin the left anterior descending artery, obtuse marginal branch and the posterolateral and posterior descending coronary arteries with excellent flow. The postoperative course was uneventful and follow-up angiography was obtained 20 days after the surgery. Coronary angiography demonstrated a saccular aneurysm（10 × 9 mm）originating at the distal segment of the left main coronary artery with 90% stenosis, andexcellent patency of both saphenous vein grafts. Follow-up angiography was performed 1 and 3 years afterthe surgery. The size of the left main coronary aneurysm remained unchanged at both examinations. The
patient did well with no further cardiac symptoms after 5 years.
─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2004 Nov ; 44（5）: 201−205

Key Words
Aneurysms left main coronary aneurysm
Coronary artery disease three-vessel obstruction

INTRODUCTION
Coronary artery aneurysms are defined as dilatations of more than 1.5 times that of the diameter of
the adjacent normal coronary segment1,2）. The incidence of coronary artery aneurysm on routine
angiography in adults ranges from 1 to 5% 1,3）.
Almost all coronary artery aneurysms observed in
adults more than 56 years old are caused by atherosclerosis4）. However, left main coronary aneurysms
are very rare3,5−7）. We report a left main coronary
aneurysm initially detected as severe three-vessel

Cardiac surgery bypass grafting

obstruction.
CASE REPORT
A 68-year-old woman with recurrent chest pain
was referred to our institution, and admitted under adiagnosis of unstable angina. She had a 2-year history of angina pectoris. Her risk factors for coronary artery disease included hypertension andhyperlipidemia. She had no history of childhood illness compatible with Kawasaki disease or any evidence of vasculitis or past trauma to the chest. Onadmission, she had a blood pressure of 130/──────────────────────────────────────────────
綜合病院社会保険徳山中央病院 循環器内科 : 〒 745−0822 山口県周南市孝田町 1−1
Division of Cardiology, Tokuyama Central Hospital, Yamaguchi
Address for correspondence : WAKEYAMA T, MD, Division of Cardiology, Tokuyama Central Hospital, Koda-cho 1−1, Shunan,Yamaguchi 745−0822
Manuscript received March 10, 2004 ; revised May 11 and 25, 2004 ; accepted May 25, 2004201

202ⅠⅡⅢ

Wakeyama, Ogawa, Takaki et al

V1V2

V3Fig. 2 Chest radiograph after coronary angiography

aVR

V4aVL

V5aVF

V6Fig. 1 Electrocardiogram on admission

76 mmHg, and a regular pulse of 80 beats/min.
Clinical chemistry examinations found no abnormalities. Electrocardiography showed ST depression in the Ⅰ, Ⅱ, aⅤL and precordial leads（Fig.
1）. Chest radiography showed slight cardiomegaly
and cardiothoracic ratio of 59%, but no pulmonary
vascular congestion（ Fig. 2）. Echocardiography
revealed diffuse hypokinesis and ejection fractionof 36%. Coronary angiography showed 100%
obstruction of the left main trunk and 100%
obstruction of the proximal right coronary arterywith good collaterals to the left anterior descending
artery and left circumflex artery along the conus
artery（Fig. 3）. None of the other arteries could beidentified as collateral source arteries. Based on theresults of the coronary angiography, intraaortic balloon pumping was introduced from the left femoralartery.

As the patient had recurrent acute coronary syndrome and high-grade obstructions of the left andright coronary arteries, surgical revascularization
was undertaken with two saphenous vein grafts.
The grafts were placed in the left anterior descending artery, obtuse marginal branch, and posterolateral and posterior descending coronary arteries.
Excellent flow was obtained in both grafts. The
postoperative course was uneventful. Electrocardiography showed improvement of ST depression
and decline of the R wave voltage compared withthe preoperative levels（Fig. 4）. Echocardiography
revealed improvement of left ventricular wallmotion with 60% ejection fraction. Follow-up
angiography was obtained 20 days after the surgery.
Coronary angiography demonstrated a large saccular aneurysm（10 × 9 mm）originating at the distalsegment of the left main coronary artery with 90%
stenosis（Fig. 5−upper）, and excellent patency ofboth saphenous vein grafts（Fig. 6）. The patientrefused further therapy for the left main coronary
aneurysm, so she was treated by medical therapy inlieu of surgical resection or coated stent implantation. Follow-up angiography was performed 1 and3 years after the surgery. The size of the left main
coronary aneurysm remained unchanged at both. The patientexaminations（Figs. 5−middle, lower）
did well with no further cardiac symptoms after 5years.
DISCUSSION
This case presents two unusual features. First,
left main coronary aneurysm is a very rare
disorder3−7）. Second, the conus branch was the only
J Cardiol 2004 Nov; 44（5）: 201 – 205

Left Main Coronary Aneurysm and Three-Vessel ObstructionFig. 3 Coronary angiograms
Upper : Occlusion of the left main trunk（arrow）.
Lower : 100% obstruction of the proximal right coronary artery with good collaterals to the left anterior
descending artery and left circumflex artery along theconus artery.

coronary artery spared from significant atherosclerotic disease8）. The latter feature was to be expected
given that the critical stenosis affected all threevessel obstructions, including the left main stem.
The etiological precursors to coronary aneurysms
include atherosclerosis, trauma, angioplasty, systemic lupus erythematosus, arteritis, dissection,syphilis, and mycotic emboli 5）. However, thispathology is mainly associated with atherosclerosis4,6）. Our patient s history and laboratory findings included no indicators suggestive of active
vasculitis or endocarditis as the underlying disease,so the atherosclerotic etiology seems most probaJ Cardiol 2004 Nov; 44（5）: 201 – 205

Ⅰ

V1

Ⅱ

V2

Ⅲ

V3aVR

V4aVL

V5aVF

V6203

Fig. 4 Electrocardiogram at 20 days after surgery

ble. Moreover, the findings of associated coronary
stenoses in our patient strongly implicate an atherosclerotic process.
The main complications of coronary aneurysms
are severe coronary stenosis, thrombosis, distalembolization, and rupture. Operative therapy is recommended for large left main coronary aneurysms
because of their predisposition to thrombosis andembolism 9）. Coexisting significant obstructive
coronary artery disease may be important in making a decision for the operative treatment inpatients with left main coronary aneurysm. The
choice between medical and surgical treatment forleft main coronary aneurysm patients can be difficult to make. The severity of the stenosis may
require revascularization by bypass surgery 5）orcoated stent10）. The surgical modalities include isolation, resection, reconstruction, or ligation of the204

Wakeyama, Ogawa, Takaki et al

Fig. 6 Coronary angiograms showing saphenous vein
graftsUpper : Patent saphenous vein graft to the left anterior
descending artery.
Lower : Patent saphenous vein graft to the obtuse marginal branch and the posterolateral and posterior
descending coronary arteries.

Fig. 5 Left coronary angiograms demonstrating a saccular aneurysm originating at the distal segmentof the left main coronary artery with 90% stenosis
Upper : 20 days after surgery.
Middle : 1 year after surgery.
Lower : 3 years after surgery.

left main coronary aneurysm with concomitant
myocardial revascularization to eliminate the riskof aneurysm rupture and distal embolization. In ourcase, the left main coronary aneurysm was onlyidentified after the coronary bypass surgery, so theaneurysm was not resected nor ligated. The left
main coronary aneurysm has not yet shown any
signs of expansion, but careful follow-up is
nonetheless required.
The conus artery was the only active coronary
artery because of the critical three-vessel obstruction. Our patient owed her survival to this conus
artery, which efficiently collateralised the left coronary artery. Her hemodynamics remained stable,
probably due to the good collaterals for her angina
J Cardiol 2004 Nov; 44（5）: 201 – 205

Left Main Coronary Aneurysm and Three-Vessel Obstruction

over the previous 2 years. In view of her uneventful
postoperative course, we conclude that no thrombus
obstructed the left main coronary aneurysm before
operation. We believe that the worsening angina
was probably caused by a plaque rupture of the left
main coronary artery rather than an obstruction by
thrombus formation inside the left main coronary
要205

aneurysm.
In general, patients with coronary aneurysm who
undergo surgical treatment have a good prognosis9）.
However, our patient refused to undergo surgicalresection or ligation of the left main coronary
aneurysm. Her clinical course will have to be carefully observed in view of the ongoing risk ofaneurysm rupture and distal embolization.
約3 枝近位部完全閉塞に左冠動脈主幹部動脈瘤を合併した 1 例分山隆敏

小 川宏

高 木昭

岩見木村征靖田中健雄

内海仁志孝景症例は 68 歳の女性で，頻繁に起こる胸痛のため当科に搬送された．冠動脈造影上，左冠動脈主幹部と右冠動脈に完全閉塞が認められ，円錐動脈から左冠動脈に向かう良好な側副血行が認められた．緊急冠動脈バイパス術を行い，2 本の大伏在静脈を用い前下行枝と回旋枝および右冠動脈に吻合した．術後の経過は良好で，術後 20 日目に確認冠動脈造影を行った．冠動脈造影上，左冠動脈主幹部から派生したå状動脈瘤（10 × 9 mm）が認められ，主幹部に 90% 狭窄を伴っていた．2 本の大伏在静脈バイパスグラフトは良好に開存していた．手術から 1 年目と 3 年目に冠動脈造影を行ったが，左主幹部冠動脈瘤の大きさは変化は認められなかった．患者は術後 5 年経過した現在も心症状なく，経過は良好である．

J Cardiol 2004 Nov; 44（5）: 201−205

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