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\begin{document}

\title{The ball is in your court}



\author[1]{Dimos Karangelis}%
\author[2]{CHRISTOS ALEXIOU}%
\author[1]{Zisis Gerontitis}%
\author[1]{Dimitrios  Mikroulis}%
\affil[1]{Demokriteio Panepistemio Thrakes Tmema Iatrikes}%
\affil[2]{Mediterraneo Hospital}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
In this paper, we describe a rare case of a giant aneurysm of the
circumflex artery that we managed. A 59-year-old female patient
presented in cardiogenic shock after partial aneurysm rupture. Giant
aneurysms of the circumflex artery are extremely rare entities. The
optimal surgical management dictates meticulous preoperative planning
and the operation should be carried out on an elective basis.%
\end{abstract}%



\sloppy


The ball is in your court

Dimos Karangelis\textsuperscript{1}, PhD, Christos
Alexiou\textsuperscript{2}, FRCS, Zisis Gerontitis\textsuperscript{1},
MD, Dimitrios Mikroulis\textsuperscript{1}, PhD

1-Department of Cardiac Surgery, Democritus University of Thrace,
University Hospital Of Alexandroupolis, Greece

2-Department of Cardiac Surgery, Mediterraneo Hospital, Glyfada, Greece

\emph{Short title: Giant coronary aneurysm}

Corresponding Author: Dimos Karangelis MD, PhD, Department of Cardiac
Surgery, Democritus University of Thrace, University Hospital of
Alexandroupolis, Greece. Email dimoskaragel@yahoo.gr,
dkarange@med.duth.gr. Tel: (+30)2551351166. Fax: (+30)25513 51164

Acknowledgements: ``None''

Funding: ''None''

Conflict of interest: ''None''

Keywords: coronary aneurysm, giant aneurysm, urgent surgery, cardiac
tamponade

Abstract

In this paper, we describe a rare case of a giant aneurysm of the
circumflex artery that we managed. A 59-year-old female patient
presented in cardiogenic shock after partial aneurysm rupture. Giant
aneurysms of the circumflex artery are extremely rare entities. The
optimal surgical management dictates meticulous preoperative planning
and the operation should be carried out on an elective basis.

The ball is in your court

Coronary artery aneurysm is defined as coronary dilatation which exceeds
the diameter of the normal adjacent artery segments or the diameter of
the patient's largest coronary artery by 1.5 times {[}1{]}. The
``giant'' CAA definition is still controversial, however according to
the Committee of the American Heart Association giant aneurysms are
defined as those \textgreater{}8mm\textsuperscript{1}.

Herein we present we describe the surgical management of 59-year-old
female patient who presented with a giant coronary aneurysm. The patient
was urgently transferred to our department for management of a giant
aneurysm of the left circumflex artery (LCx) measuring 10 by 12 cm
(Figure 1A, B). The patient was on another hospital's surgical list
waiting to be operated. The operation had delayed due to covid-related
issues and the patient was experiencing daily angina-like symptoms. Upon
arrival, the patient was in a critical condition due to cardiac
tamponade, requiring high doses of inotropic support. She underwent
urgent cardiac surgery. The operation was conducted under
cardiopulmonary bypass which was established via femoral aortic and
venous access. The venous cannula was later transitioned to a 2-stage
right atrial cannula due to poor drainage. After median sternotomy, 500
ml of blood and clots were removed from the pericardial sac. The
aneurysm had spontaneously ruptured and involved the left circumflex
coronary artery, occupying most of the inferior surface of the left
ventricular wall and its size was displacing the heart superiorly and
anteriorly, causing compression to the adjacent arteries. The patient's
preoperative echocardiogram, besides the tamponade was evident of a
reduced ejection fraction. The aneurysmal sac was opened and the inflow
and outflow points were suture ligated (Figure 1C). A vein graft was
anastomosed end-to-side to the coronary artery distally, while the
aneurysmal cavity was obliterated by multiple sutures.

The patient was weaned from cardiopulmonary bypass requiring high doses
of inotropic support and intra-aortic balloon pump assistance. She
succumbed several hours later in the intensive care unit. Patients
suffering from coronary aneurysms are often asymptomatic. Nevertheless,
sometimes depending on the size of the aneurysm, they may present with
symptoms of angina\textsuperscript{2}. Coronary aneurysms may be
complicated with rupture, thrombosis, embolism and fistula to the
cardiac chambers\textsuperscript{2}. Most giant coronary aneurysms
reported in the medical literature have involved the RCA adjacent to the
right atrium\textsuperscript{3}.

To the best of our knowledge, this is the one of the largest giant
aneurysms ever reported in literature, involving the circumflex artery
(Figure 1, D). Such aneurysms necessitate careful preoperative planning
and should be operated on an elective basis.

Author contributions

DK and CA : Writing of the article

ZG : Literature review and drafting

DM: Approval of article

References

1.Wang H, Zhang Y, Xie Y,~Wang H, Yuan J. Giant right coronary artery
aneurysms presenting as a cardiac mass.Medicine (Baltimore). 2016
Sep;95(38):e4924. doi: 10.1097/MD.0000000000004924

3. Marla R, Ebel R, Crosby M, Almassi GH. Multiple giant coronary artery
aneurysms. Tex Heart Inst J. 2009;36(3):244-6.

4. Li D, Wu Q, Sun L, Song Y, Wang W, Pan S, et al. Surgical treatment
of giant coronary artery aneurysm. J Thorac Cardiovasc Surg
2005;130(3):817--21

Acknowledgements: ``None''

Funding: ''None''

Conflict of interest: ''None''

The authors confirm that informed consent was obtained~by the patient

Figure legends

A. Preoperative CT. The aneurysm measured 10 x12 cm. B. Coronary
angiography. C. The aneurysmal sac was opened and the inflow (entry)
point is visible D. Intraoperative image of the aneurysm (from patient's
head)\selectlanguage{english}
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