Anterior Descending Coronary Artery Pseudoaneurysm in an 85-Year-Old Male Hemodialysis Patient: A Surgical Case Report

Abstract

BACKGROUND Coronary artery pseudoaneurysm is an extremely rare condition. In this report, we describe an 85-year-old hemodialysis male patient who developed a coronary artery pseudoaneurysm due to physical damage associated with coronary artery calcification. CASE REPORT An 85-year-old man on hemodialysis had undergone emergency percutaneous coronary intervention of the left anterior descending artery for acute coronary syndrome 9 years ago. He presented to the emergency room with a fever and chest pain and was admitted to the cardiology department with a urinary tract infection and acute coronary syndrome. On day 21 after admission, when the urinary tract infection had resolved, coronary angiography was performed, which revealed a pseudoaneurysm proximal to the left anterior descending artery stent. The patient was scheduled to undergo surgery due to the pseudoaneurysm's risk of rupture. Surgical manipulation was performed under cardiac arrest using the median sternotomy approach. A highly calcified coronary intima was found inside the pseudoaneurysm, which was completely ruptured on the proximal side of the pseudoaneurysm. The pseudoaneurysm was closed after endarterectomy. A coronary artery bypass graft was also performed in the great saphenous vein graft of the left anterior descending artery. Histopathological examination showed no obvious signs of infection, and a diagnosis of pseudoaneurysm was established. Postoperative contrast-enhanced computed tomography showed patency of the coronary artery bypass graft and no pseudoaneurysm recurrence. CONCLUSIONS Coronary artery pseudoaneurysms are extremely rare, but this case demonstrates that atherosclerotic changes can lead to the formation of a pseudoaneurysm in an elderly hemodialysis patient.

Figure 1.

Preoperative plain and contrast CT findings and coronary angiography. Coronary artery pseudoaneurysm (arrow) was absent on computed tomography (CT) on admission (A) but appeared on contrast-enhanced CT 21 days after admission (B). It was also obvious in the left anterior descending artery on three-dimensional CT (C) and coronary angiography (D). Ao – aorta; LA – left atrium; LAD – left anterior descending artery; LCX – left circumflex artery; PA – pulmonary artery; RA – right atrium; RCA – right coronary artery.

Figure 2.

Intraoperative findings. The pseudoaneurysm wall was adherent to the pericardium (A, arrowhead). When the pseudoaneurysm was incised, the coronary artery intima was highly calcified and completely ruptured on the proximal side of the pseudoaneurysm (B, arrow). After endarterectomy (C), the aneurysm wall was closed (D).

Figure 3.

Pathological findings. (A) (Hematoxylin and eosin stain ×1): Edematous fibrosis and mild lymphocytic infiltration were observed in the adipose tissue surrounding the coronary artery (star). The area outlined by the rectangle is enlarged and shown in (B). (B) (Elastica van Gieson stain ×40): Elastic fibers were broken and lost in part of the tunica media of the coronary artery. The external elastic lamina was also lost (arrows). The resulting coronary artery wall was swollen (asterisk). No bacterial or neutrophilic infiltration nor any obvious signs of infection were evident.

Figure 4.

Postoperative CT findings two months after surgery. Coronary angiographic computed tomography (CT) shows the patency of the bypass graft to the LAD and no pseudoaneurysm recurrence (arrows) (A: horizontal section; B: three-dimensional-CT). Ao – aorta; LA – left atrium; PA – pulmonary artery; RA – right atrium.