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.