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Case Reports
. 2025 Oct 29;30(34):105611.
doi: 10.1016/j.jaccas.2025.105611.

Recurrent Left Main Occlusion in Pediatric Kawasaki Disease: Surgical Patch Angioplasty With Autologous Pulmonary Trunk

Woan Shiang See  1 , Jonathan H Weale  2 , Alain Fraisse  3 , Andreas Hoschtitzky  4 , David J Barron  4
Affiliations
Case Reports

Recurrent Left Main Occlusion in Pediatric Kawasaki Disease: Surgical Patch Angioplasty With Autologous Pulmonary Trunk

Woan Shiang See et al. JACC Case Rep. .

Abstract

Background: Coronary ostial stenosis is a particularly rare but life-threatening complication in children with Kawasaki disease, posing significant anatomical and technical challenges for surgical management.

Case summary: We report the case of a child with Kawasaki disease who developed recurrent left main coronary artery occlusion, presenting initially with cardiac arrest, and required emergency extracorporeal membrane oxygenation support. He underwent multiple revascularization procedures, including percutaneous coronary intervention and coronary artery bypass grafting (CABG), both of which ultimately failed. Persistent myocardial ischemia necessitated surgical patch angioplasty (SPA) of the left main stem using an autologous pulmonary trunk patch.

Discussion: Although surgical revascularization including CABG is commonly performed in cases of severe left main coronary artery occlusion, the potential role of SPA in pediatric patients remains underexplored.

Take-home message: SPA using autologous pulmonary artery offers a potentially advantageous alternative for coronary reconstruction in small children, particularly in cases of isolated proximal coronary stenosis or where traditional CABG may be technically challenging or unsustainable owing to small conduit caliber.

Keywords: Kawasaki disease; left main coronary artery occlusion; ostial coronary stenosis; revascularization; surgical patch augmentation.

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Conflict of interest statement

Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Preoperative Coronary CT Angiography Coronary CT angiography demonstrated complete occlusion of the ostial LMCA within the stented LMCA. CT = computed tomography; LMCA = left main coronary artery.
Figure 2
Figure 2
Intraoperative Images (A) The ascending aorta and pulmonary trunk were transected to expose the course of the LMS from the ostium to the bifurcation. A 0.5-mm probe was able to be passed from the aortic lumen across the occluded lumen within the origin of the LMS. (B) Surgical opening of the occluded stented LMS. With guidance from the coronary probe, the stented LMS was carefully opened into the proximal LAD up to the bifurcation, where it had opened out to a 2.5-mm vessel. The stent struts were debrided, and a patch of autologous pulmonary trunk was harvested to augment the LMS using 7-0 Prolene sutures. A 2.5-mm coronary shunt was used to control blood flow during the anastomosis. (C) Patch-augmented LMS with widely patent LMCA augmentation as assessed with 2-mm probe down into the proximal LAD. LAD = left anterior descending artery; LMCA = left main coronary artery; LMS = left main stem; MPA = main pulmonary artery; PA = pulmonary artery; STJ = sinotubular junction.
Figure 3
Figure 3
Postoperative Coronary CT Angiography Coronary CT angiography on postoperative day 5 confirmed a widely patent reconstructed LMCA, with uninterrupted lumen from the ostium to beyond its bifurcation. CT = computed tomography; LMCA = left main coronary artery.
Visual Summary
Visual Summary
Case Presentation and Surgical Procedure (A) The clinical course of a 6-year-old boy with a history of Kawasaki disease complicated by progressive coronary artery disease. Key milestones are mapped chronologically. (B) Surgical patch angioplasty for LMS occlusion. Top left: Preoperative coronary CT angiography shows complete occlusion of the stented LMS (arrow). Bottom left: Postoperative coronary CT angiography demonstrates restored patency of the LMS after SPA. Right panel: Intraoperative image showing the surgical field during SPA. The aorta is transected at the STJ, and the MPA is transected to improve exposure. The occluded coronary ostium is debrided, and a coronary shunt is placed to improve exposure of the lumen. An autologous PA patch is used to reconstruct the LMS. CT = computed tomography; KD = Kawasaki disease; LIMA = left internal mammary artery; LMCA = left main coronary artery; LMS = left main stem; MPA = main pulmonary artery; PA = pulmonary artery; PCI = percutaneous coronary intervention; SPA = surgical patch angioplasty; STJ = sinotubular junction; VA-ECMO = venoarterial extracorporeal membrane oxygenation.
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