Global Endovascular or Surgical Treatment: A Challenging Case of Combined Coronary Artery, Abdominal Aorta and Iliac Arteries

The presence of coronary artery aneurysm (CAA) is revealed in 1–4% of coronary angiography1 but the association with aortic abdominal aneurysm (AAA) is only anecdotal.2–3 Atherosclerosis (50% of cases)1 and more rarely, Marfan disease,4 Kawasaki disease5 and rheumatoid arthritis6 are considered the main causes of coronary aneurysms, while atherosclerosis (80% of cases) and inflammation (3–10% of cases)7 constitute practically the only etiologies of aortic abdominal aneurysms. No association of CAA with inflammatory AAA has been reported thus far. We present a case of CAA and inflammatory AAA in which staged surgical treatment of both diseases was performed instead of endovascular management. Case Report. A 51-year-old caucasian man with a history of high blood pressure and smoking was admitted to our center for an acute antero-lateral myocardial infarction. Physical examination revealed an exaggerated pulsating abdominal mass. Laboratory tests showed an increased erythrocyte sedimentation rate and elevated C-reactive protein values. Echocardiography detected a low left ventricular ejection fraction (37%) and anterolateral akinesis with ventricular aneurysm. The substernal projection revealed an enlargement of the abdominal aorta suggesting an aortic aneurysm. The patient underwent coronary angiography that revealed multiple aneurysms and occlusive disease of both the left and right coronary arteries (Figure 1A), while aortography revealed the presence of a voluminous aortic abdomino-iliac aneurysm (Figure 1B). The angio-CT confirmed a large abdomino-iliac aortic abdominal aneurysm of > 8 cm in diameter with a true lumen of 6 cm with hydronephrosis and retroperitoneal fibrosis and increased enhancement of the external aortic wall at delayed scansions suggesting the presence of an inflammatory disease (Figure 1C). The neck was judged insufficient for conventional endovascular repair ( Discussion. The association between coronary artery aneurysm and abdominal aneurysm is extremely rare and has only been anecdotally reported in the English literature.2–3 In the Japanese literature, some authors reported such an association in relation to Bechet’s syndrome.8 To the best of our knowledge, no report exists of a combined inflammatory abdominal aneurysm and coronary artery aneurysmal disease. Our case presented all the typical characteristics of an inflammatory disease: high ESR, high level of C-reactive protein and compression of the ureter were present as described by many authors.9–11 We thought that a unique inflammatory etiology was a real possibility because the angiographic appearance of coronary disease was not typical for the atherosclerotic process but more similar to that shown in cases of Kawasaki’s or Takayasu’s disease. Recently, a common pathogenesis for atherosclerotic and inflammatory aneurysmal disease has been suggested: common inflammatory stimuli such as tobacco and genetic factors may be involved in the pathogenesis of both inflammatory and atherosclerotic aneurysms.7 Despite recent reports on the feasibility of endovascular grafting in inflammatory aortic aneurysm,12,13 doubts persist about its real efficacy in decreasing the retroperitoneal fibrosis and future long-term effects. Some authors have reported increased early and late mortality rates and progression of peri-aortic fibrosis,14,15 whereas others have described complete success.16,17 Due to the low left ventricular ejection fraction and a possible worsening of hydronephrosis, we considered that it would be ill advised to pursue surgical myocardial revascularization followed by suprarenal endografting fixation with an adjunctive bell-bottom technique to seal the common iliac arteries. In conclusion, pending definitive evidence of endografting benefits for inflammatory aneurysm, in the case of systemic aneurysmal involvement, the treatment strategy should be tailored to the degree of coronary artery disease. In the case of ischemically impaired cardiac function, an aggressive combined surgical approach is preferable in order to minimize possible heart failure due to any worsening of both peri-aortic fibrosis and renal function. Acknowledgements. The authors gratefully acknowledge the invaluable competence and assistance of Mrs. Anne Holdstock in the preparation of this article. How Would You Manage This Case? Gerald Dorros MD, FACC William Dorros-Isador Feuer Interventional Cardiovascular Disease Foundation Phoenix, Arizona This young patient has aneurysmal and obstructive coronary disease, mildly diminished left ventricular function and a significantly large abdominal aortic aneurysm. The words of Clint Eastwood’s character Harry Callahan, “A man must know his limitations!” are appropriate and poignant. While an attempt could have been made to use stents, in whatever form, to possibly relieve the coronary obstructions, our long-term knowledge of what will result in the presence of possible inflammatory coronary aneurysmal disease is unknown. Furthermore, since multivessel disease is present, the long-term benefit to the patient would be more than satisfactory if revascularization were accomplished with an internal mammary artery implanted into the left anterior descending artery. The abdominal aortic aneurysm with its probable inflammatory process makes classic surgical intervention more difficult, but with the short infra-renal neck, the use of an endovascular device would be difficult as well, and the long-term problems of reintervention would remain. Thus, the age of the patient and his relatively good left ventricular function makes the open procedure the therapy of choice. Thus, I agree entirely with the management of this patient, as presented, and ask physicians to always consider all therapeutic options and what is in the patient’s best interest. Frank J. Criado, MD Director, Center for Vascular Intervention Chief, Division of Vascular Surgery Union Memorial Hospital/MedStar Health Baltimore, Maryland This case is obviously a rather complex clinical challenge. I find little to disagree with, as I would likely have managed the patient in exactly the same manner. One could argue about the possible wisdom of performing the surgical repair of AAA at the time of the CABG operation, as such combined procedures tend to be very difficult and carry increased morbidity and mortality. The information available on AAA morphology is somewhat incomplete for me to be able to pass judgement on the potential for endovascular repair using a supra-renal fixation stent-graft device. This would have been (theoretically) the most desirable course of action. Inflammatory AAAs constitute a major surgical challenge. Interestingly, large aneurysms (> 6 cm) are easier treated than small ones, where intraluminal (intra-sac) maneuvers and graft inclusion technique can become quite difficult. The duodenum and other neighboring organs tend to become very adherent to the sac; it is best to leave them alone (un-dissected) and perform the entire procedure from within the aneurysm, following proximal control and clamping (often at the supra-celiac aorta).