Saccular Coronary Artery Aneurysm and Fistula with Organized Thrombi
A 48-year-old woman, who had no history of specific conditions, such as Kawasaki's disease or chest trauma, connective tissue disorder was referred to our hospital for the evaluation of an abnormal shadow on the left cardiac border on a chest X-ray film (). She had no subjective symptoms. Her blood pressure was 120/78 mm Hg and pulse rate was 78 beats/min. On physical examination, continuous murmur of a grade II/VI was audible at 4th left intercostal space. The results of other physical examination and blood test were normal. An electrocardiogram showed sinus rhythm and no ST-T wave changes. Transthoracic echocardiography demonstrated a 4.1×4.0 cm round cystic mass with internal echogenecity in the wall, located in contact with upper anterolateral wall of the left ventricle and coronary artery fistula opening to main pulmonary trunk (). Chest MDCT showed a 5 cm saccular aneurysm of proximal left anterior descending artery (LAD) with organized thrombi and multiple fistulae from the conus artery, LAD and aneurysmal sac to the main pulmonary trunk (). Coronary angiography revealed a huge saccular aneurysm at proximal LAD, which was filled with contrast medium in a swirling fashion with slow opacification of distal LAD (thrombolysis in myocardial infarction grade II). Moreover, there were several fistulae from the conus artery of right coronary artery (RCA), proximal LAD, and aneurysmal sac to the pulmonary artery ().\nAfter the diagnosis, she underwent surgery. Median sternotomy was performed. Two vessels from proximal RCA were identified (). One of them, a fistula from the conus branch to pulmonary artery, were clamped and ligated. After the initiation of cardiopulmonary bypass, the aorta was cross-clamped. When coronary aneurysmal sac was opened, the sac was filled with organized thrombi, which were removed (). Then, the inlet and outlet of aneurysmal sac were ligated and the left internal mammary artery was grafted to the distal LAD. After total bypass, the main pulmonary artery was opened and closed the fistula's opening site, which was observed (). The postoperative course of the patient was stable and uneventful.\nPostoperative MDCT () and echocardiography (), which was performed after 5 days and 7 days, respectively, showed patent bypass graft and successful ligation of aneurysm. However, an abnormal flow at the main pulmonary trunk regarded as a remnant fistula was still visible, although the amount of the abnormal flow was reduced. The patient was discharged, and we have planned regular check-up because the patient was free of symptoms, and the size of fistula was small.