Case Report
A 69-year-old female presented with exertional chest discomfort relieved
by nitroglycerine, typical of coronary insufficiency. Her past medical
history includes Kawasaki’s disease (KD) that was diagnosed at age 50
after investigations for an episode of retinal artery occlusion. She had
since been managed conservatively with anticoagulation with warfarin and
risk factor modification.
The current clinical presentation prompted risk stratification with
stress testing that demonstrated anterior wall ischemia. Subsequent
coronary angiogram revealed a left anterior descending coronary artery
dilation measuring 30mm in the segment with no significant luminal
stenosis (Figure 1a), a heavily calcified aneurysm of 30mm at the ostium
of the left circumflex artery (Figure 1b), and a 12mm dilation in the
proximal portion of the right coronary artery that was free of
angiographically significant stenosis (Figure 1c). Additional smaller
aneurysms were visualized in the proximal first obtuse marginal and
mid-second obtuse marginal arteries.
This patient was found to have new onset of unstable angina in the
setting of multiple giant coronary aneurysms, with no evidence of
significant atherosclerotic plaque. She had been on thromboembolic
prophylaxis with warfarin maintained at a therapeutic international
normalized ratio of 2-3 since the time of KD diagnosis. She was also
placed on antiplatelet agents but continued to be symptomatic with
angina. In the setting of optimal medical management and ongoing
symptoms with known coronary aneurysms, coronary artery bypass surgery
was recommended. As a result, a 3-vessel coronary artery bypass grafting
(CABG) was successfully performed with a left internal mammary grafting
to the mid-left anterior descending artery, saphenous vein graft to the
posterior-lateral ventricular branch of the distal left circumflex
artery, and saphenous vein graft to the distal right coronary artery. At
6-month and 1-year postoperative follow-up, the patient reports marked
improvement with complete resolution of her symptoms after CABG, now
NYHA class 1.