Advertisement
Mayo Clinic Proceedings Home

Asymptomatic Occlusion of the Left Main Coronary Artery by an Aortic Pseudoaneurysm

      Extrinsic compression of the left main coronary artery is a rare cause of coronary ischemia. We describe a 35-year -old Asian woman with complete asymptomatic occlusion of the left main coronary artery by a large aortic pseudoaneurysm. She underwent repair of the pseudoaneurysm and coronary artery bypass grafting at the Mayo Clinic in Rochester, Minn. The differential diagnosis is discussed. Based on this patient's age and associated vascular lesions, we conclude that Takayasu arteritis was the most likely cause of her condition.
      Extrinsic compression of the left main coronary artery is uncommon and usually presents with symptoms of coronary ischemia, including sudden death. We describe a 35-year-old Asian woman whose left main coronary artery was compressed by a large pseudoaneurysm of the proximal ascending aorta.

      REPORT OF A CASE

      In a 35-year-old Asian woman who was born in the Philippines and immigrated to the United States in her early 20s, chest radiography disclosed a mass located close to the left pulmonary hilum (Figure 1). The chest radiograph was obtained during a work-up for recently diagnosed hypertension. The patient was asymptomatic, and her medical history was otherwise unremarkable. Malignancy was suspected, and a biopsy of the mass was performed from a sternotomy approach. However, the biopsy yielded a blood clot both grossly and on histological examination. The procedure was stopped, and the patient was referred to the Mayo Clinic in Rochester, Minn, for further evaluation.
      Figure thumbnail gr1
      Figure 1Lateral chest radiograph shows a partially calcified mass (arrowheads) close to the aortic root. It projected over the left pulmonary hilum on a posteroanterior projection.
      Results of the patient's physical examination were normal, including peripheral pulses. Electrocardiography showed sinus tachycardia and T-wave changes in anteroseptal leads consistent with ischemia. Rapid plasma reagin and antinuclear antibody tests were negative, and the erythrocyte sedimentation rate was normal. The total cholesterol value was 221 mg/dL, and the calculated low-density lipoprotein value was 130 mg/dL.
      Transesophageal echocardiography showed a large, laminated mass adjacent to and communicating with the left aortic sinus. Findings on the rest of the examination were unremarkable, except for mild hypokinesis of the anterior septum and apparent moderate aortic atherosclerosis unusual for the patient's age. The diagnoses of thrombosed sinus of Valsalva aneurysm and aneurysm of the left main coronary artery were contemplated.
      The patient was referred for coronary angiography Attempted injection of the left main coronary artery led to partial opacification of the mass. The left main coronary artery itself was occluded (Figure 2, A). Injection of the right coronary artery showed that this large vessel supplied the whole myocardium through extensive collateral vessels to the left anterior descending and especially circumflex vessels, which showed retrograde filling (Figure 2, B). The proximal left anterior descending and proximal circumflex arteries were also occluded. Injection of the aortic root further delineated the anatomy of the pseudoaneurysm and revealed mild aortic regurgitation (Figure 2, C).
      Figure thumbnail gr2
      Figure 2A, Attempted injection of the left main coronary artery in a left anterior oblique projection resulted in opacification of the pseudoaneurysm, which was partially filled with thrombus. Note the thin shell of calcification in the wall of the large pseudoaneurysm (arrowheads). B, Contrast injection of the right coronary artery in a left anterior oblique projection shows extensive retrograde filling of the territory of the circumflex and left anterior descending arteries through rich collateral vessels. C. Contrast injection of the ascending aorta in a left anterior oblique projection. The neck (arrow) of the pseudoaneurysm can be clearly appreciated.
      Subsequent magnetic resonance imaging of the heart demonstrated an elliptical aneurysm (6 × 3 cm) arising from the posterolateral aspect of the ascending aorta. It was filled with thrombus except for a small (1.5 em) lumen, which communicated with the aorta through a neck (Figure 3). Magnetic resonance imaging of the aorta and arch branches showed occlusion of the left subclavian artery immediately after its takeoff from the aortic arch. The vessel showed retrograde filling from the left vertebral artery. The abdominal aorta was diffusely diseased with mild aneurysmal dilatation at the level of the renal arteries, which. were widely patent.
      Figure thumbnail gr3
      Figure 3Transverse magnetic resonance image of the chest at the level of the pseudoaneurysm. A large thrombus (T) fills most of the pseudoaneurysm, which communicates with the ascending aorta (A) and abuts the pulmonary artery (P).
      Surgical treatment was recommended, but the patient deferred this for 6 months. During the operation, the vascular lesion was identified as a pseudoaneurysm, which was partially thrombosed and communicated with the ascending aorta through a round, smooth defect about 15 mm in diameter (Figure 4). It was also compressing the right pulmonary artery. The left main coronary artery was not included in the pseudoaneurysm or its wall, and its ostium could not be identified. Resection of the pseudoaneurysm and Dacron patch repair of the ascending aorta were performed. Saphenous vein bypass grafting to the left anterior descending artery was established because neither of the internal mammary arteries was suitable for coronary bypass. Pathologically, the aortic wall surrounding the orifice of the pseudoaneurysm showed fibrocalcific neointima with degenerating thrombus, but no active infection, inflammation, medial dissection, or cystic medial degeneration was detected.
      Figure thumbnail gr4
      Figure 4Excision of the portion of the aortic wall containing the defect shows a round, smooth opening, inconsistent with a traumatic cause.
      Transthoracic echocardiography performed 5 days postoperatively showed normal left ventricular size and function and mild regurgitation of the aortic and mitral valves. The patient recovered uneventfully and was asymptomatic 16 months later.

      DISCUSSION

      Extrinsic compression of the left main coronary artery, in contrast to atherosclerotic involvement, is uncommon and usually presents with symptoms of coronary ischemia, including sudden death. Compression of this vessel between the pulmonary artery and ascending aorta can result from its anomalous origin from the right sinus of Valsalva.
      • Comfort SR
      • Curry Jr, RC
      • Roberts WC
      Sudden death while playing tennis due to a tear in ascending aorta (without dissection) and probable transient compression of the left main coronary artery.
      Multiple structures can be responsible, including a dilated pulmonary artery in the setting of primary pulmonary hypertension,
      • Patrat JF
      • Jondeau G
      • Dubourg O
      • et al.
      Left main coronary artery compression during primary pulmonary hypertension.
      atrial septal defect,
      • Kothari SS
      • Chatterjcc SS
      • Sharma S
      • Rajam M
      • Wasir HS
      Left main coronary artery compression by dilated main pulmonary artery in atrial scptal defect.
      or patent ductus arteriosus
      • Bijl M
      • Bron/waer JG
      • van Rossum AC
      • Verhcugt FW
      Angina pectoris due to left main coronary artery compression in Eisen-mengcr ductus artcriosus.
      ; perivalvular abscess of the aortic valve or mycotic aneurysm of the aortic root
      • Cripps T
      • Guvendik L
      Coronary artery compression caused by abscess formation in infective endocarditis.
      • Vilacosta I
      • Camino A
      • Sarriia C
      • et al.
      Mechanical compression of the left coronary artery resulting from periannular extension of aortic endocarditis: diagnosis by transesophageal echocardiog-raphy.
      ; aneurysm of the mitral-aortic intervalvular fibrosa
      • Parashara DK
      • Jacobs LE
      • Kotler MN
      • et al.
      Angina caused by systolic compression of the left coronary artery as a result of pseudo-aneurysm of the mitral-aortic intcrvalvular fibrosa.
      ; tumors
      • Weinberg BA
      • Pinkerton CA
      • Waller BF
      External compression by metastatic squamous cell carcinoma: a rare cause of left main coronary artery narrowing.
      ; and left ventricular aneurysm,
      • Skoularigis J
      • Sareli P
      Submitral left ventricular aneurysm compressing the left main coronary artery.
      Our patient had compression of the left main coronary artery by a large pseudoaneurysm of the proximal ascending aorta. In light of her asymptomatic presentation and excellent collateral circulation, the compression probably developed gradually over a lengthy period. The possible causes to be considered in such cases include congenital aneurysm of the sinus of Valsalva, atherosclerotic aortic aneurysm, posttraumatic pseudoaneurysm, a noninfectious inflammatory aortitis, and a mycotic, syphilitic, or tuberculous process.
      A chronic posttraumatic pseudoaneurysm is a rare sequela of blunt chest trauma.
      • Bacharach JM
      • Garratt KN
      • Rooke TW
      Chronic traumatic thoracic aneurysm: report of two cases with the question of timing for surgical intervention, y.
      The site of aortic injury is usually at the aortic isthmus
      • Parmley LF
      • Maltingly TW
      • Manion WC
      • Jahnke Jr, FJ
      Non-penetrating traumatic injury of the aorta.
      ; however, a chronic posttraumatic pseudoaneurysm involving the extrapericardial portion of the ascending aorta has been reported
      • Prater SP
      • Leya FS
      • McKiernan TL
      Post-traumatic pseudo-aneurysm of the ascending aorta-an incidental finding two decades later.
      . Apart from the unusual location, the smooth, round appearance of the aortic wall defect during operation argued against a posttraumatic cause in our patient.
      An atherosclerotic aneurysm can lead to compression of the left main coronary artery,
      • Olsen J
      Aneurysm of the aortic sinus of Valsalva: a case of rupture and myocardial infarction.
      but it would be rare in a woman of this age with an essentially normal lipid profile, and no atheroma was detected in the tissue obtained during operation.
      Congenital aneurysm of the sinus of Valsalva is a relatively uncommon anomaly, and it probably results from an incomplete fusion between the aortic media and the aortic valve annulus.
      • Boutefeu JM
      • Moret PR
      • Hahn C
      • Häuf E
      Ancurysms of the sinus of Valsalva: report of seven cases and review of the literature.
      It is more common in men, and the right sinus of Valsalva is involved in most cases. Aneurysm of the left sinus of Valsalva is rare but can cause compression of the left main coronary artery.
      • Bayada JM
      • Giordano P
      • Corncil G
      • Gibelin P
      • Jourdan J
      • Morand P
      Compression of the coronary trunk by aneurysm of the antero-left Valsalva sinus associated with acute mitral insufficiency caused by rupture of the chordae following valvular prolapse: successful triple surgical operation in a 66-year old patient [in French].
      • Brandt J
      • Jogi P
      • Luhrs C
      Sinus of Valsalva aneurysm obstructing coronary arterial flow: case report and collective review of the literature.
      This diagnosis was considered in our patient, but it failed to explain the occlusion of the left subclavian artery and the involvement of the abdominal aorta seen on magnetic resonance imaging.
      Various infections can involve the ascending aorta. Infective endocarditis can cause a mycotic aneurysm of the sinus of Valsalva with coronary artery compression,
      • Koike S
      • Takayama S
      • Furihata A
      • et al.
      Infective endocarditis causing acute myocardial infarction by compression of the proximal left coronary artery due to a mycotic aneurysm of the sinus of Valsalva.
      and involvement of the noncoronary sinus of Valsalva with tuberculosis has been reported
      • Matsumoto Y
      • Kubo T
      • Tagawa H
      • et al.
      An autopsy case of the sinus of Valsalva aneurysm involved with tuberculous inflammation, leading to complete heart block [in Japanese].
      ; however, there were no findings to support either diagnosis in our patient. A negative rapid plasma reagin result ruled out a syphilitic process, which can also produce compression of the left main coronary artery by an aneurysm of the sinus of Valsalva.
      • Chipps HD
      Aneurysm of sinus of Valsalva causing coronary occlusion.
      The aorta is frequently affected in noninfectious inflammatory arteritides, of which Takayasu arteritis is the most common.
      • Kieffer E
      • Chiche L
      • Bertal A
      • Bahnini A
      • Koskas F
      Inflammatory ancurysms of the thoracic aorta: surgical aspects [in French].
      In fact, our patient fulfills the classic Ishikawa criteria
      • Ishikawa K
      Diagnostic approach and proposed criteria for the clinical diagnosis of Takayasu's arteriopathy.
      for the diagnosis of this disease (<40 years, involvement of the left subclavian artery, hypertension, aortic regurgitation, and involvement of the abdominal aorta), except that her subclavian artery was occluded at the origin, where-as the criteria require maximal narrowing in the midportion.
      Coronary artery involvement in Takayasu arteritis has been well documented, and as many as 10% of patients may be affected. Ostial coronary artery stenoses predominate, and ostial left main coronary artery stenosis occurs in about one half of the cases.
      • Amano J
      • Suzuki A
      Coronary artery involvement in Takayasu's arteritis: collective review and guideline for surgical treatment.
      Aneurysms of coronary arteries are much less common in patients with Takayasu arteritis. However, our patient had extrinsic compression of a coronary artery by an aortic pseudoaneurysm rather than direct coronary involvement.
      Arterial aneurysms were described in 8 (9.1%) of 88 patients with Takayasu arteritis in 1 series and may be associated with hypertension.
      • Sharma S
      • Rajani M
      • Kamalakar T
      • Kumar A
      • Talwar KK
      The association between aneurysm formation and systemic hypertension in Takayasu's arteritis.
      An aneurysm of the left sinus of Valsalva compressing the left main coronary artery was reported in a 45-year-old Japanese woman with Takayasu arteritis.
      • Nakano T
      • Okano H
      • Konishi T
      • Takczawa H
      Aneurysm of the left aortic sinus caused by Takayasu's arteritis: compression of the left coronary artery producing coronary insufficiency.
      She had an acute myocardial infarction and subsequently declined coronary artery bypass grafting.
      Other noninfectious vasculitides that can result in aortic aneurysm formation are giant cell arteritis,
      • Evans JM
      • Bowles CA
      • Bjomsson J
      • Mullany CJ
      • Hunder GG
      Thoracic aortic aneurysm and rupture in giant cell arteritis: a descriptive study of 41 cases.
      • Klein RG
      • Hunder GG
      • Stanson AW
      • Sheps SG
      Large artery involvement in giant cell (temporal) arteritis.
      rheumatoid arthritis,
      • Gravallese EM
      • Corson JM
      • Coblyn JS
      • Pinkus GS
      • Weinblalt ME
      Rheumatoid aortitis; a rarely recognized but clinically significant entity.
      Behçet discase.
      • Roguin A
      • Edoute Y
      • Milo S
      • Shtiwi S
      • Markiewicz W
      • Reisner SA
      A fatal case of Behcet' s disease associated with multiple cardiovascular lesions.
      • Freyrie A
      • Paragona U
      • Cenacchi G
      • Pasquinelli G
      • Guiducci G
      • Faggioli GL
      True and false aneurysms in Behçcl's disease: case report with ultrastructural observations.
      Cogan syndrome,
      • Ferrari E
      • Taillan B
      • Gamier G
      • Dor V
      • Morand P
      • Dujardin P
      Cardiovascular manifestations of Cogan syndrome: apropos of a case [in French].
      and relapsing polychondritis.
      • Cipriano PR
      • Alonso DR
      • Baitaxe HA
      • Gay Jr, WA
      • Smith JP
      Multiple aortic aneurysms in relapsing polychondritis.
      Compared with Takayasu arteritis, these are all considerably less likely to explain the aortic lesion in our patient in light of her age, the lack of arthritis or mucosal lesions, the absence of keratitis and otovestibular symptoms, and no apparent cartilage involvement.

      CONCLUSION

      Based on our patient's age, sex, ethnicity, and involvement of the abdominal aorta and subclavian artery, a prior episode of Takayasu arteritis seems to be the most likely cause of her aortic pseudoaneurysm. Although a case of compression of the left main coronary artery by an aortic aneurysm in a patient with Takayasu arteritis has been reported, the asymptomatic presentation of our patient is remarkable.

      REFERENCES

        • Comfort SR
        • Curry Jr, RC
        • Roberts WC
        Sudden death while playing tennis due to a tear in ascending aorta (without dissection) and probable transient compression of the left main coronary artery.
        Am J Cardiol. 1996; 78: 493-495
        • Patrat JF
        • Jondeau G
        • Dubourg O
        • et al.
        Left main coronary artery compression during primary pulmonary hypertension.
        Chest. 1997; 112: 842-843
        • Kothari SS
        • Chatterjcc SS
        • Sharma S
        • Rajam M
        • Wasir HS
        Left main coronary artery compression by dilated main pulmonary artery in atrial scptal defect.
        Indian Heart J. 1994; 46: 165-167
        • Bijl M
        • Bron/waer JG
        • van Rossum AC
        • Verhcugt FW
        Angina pectoris due to left main coronary artery compression in Eisen-mengcr ductus artcriosus.
        Am Heart J. 1993; 125: 1767-1771
        • Cripps T
        • Guvendik L
        Coronary artery compression caused by abscess formation in infective endocarditis.
        Int J Cardiol. 1987; 14: 99-102
        • Vilacosta I
        • Camino A
        • Sarriia C
        • et al.
        Mechanical compression of the left coronary artery resulting from periannular extension of aortic endocarditis: diagnosis by transesophageal echocardiog-raphy.
        Am year. 1994; 128: 823-827
        • Parashara DK
        • Jacobs LE
        • Kotler MN
        • et al.
        Angina caused by systolic compression of the left coronary artery as a result of pseudo-aneurysm of the mitral-aortic intcrvalvular fibrosa.
        Am Heart J. 1995; 129: 417-421
        • Weinberg BA
        • Pinkerton CA
        • Waller BF
        External compression by metastatic squamous cell carcinoma: a rare cause of left main coronary artery narrowing.
        Clin Cardiol. 1990; 13: 360-366
        • Skoularigis J
        • Sareli P
        Submitral left ventricular aneurysm compressing the left main coronary artery.
        Cathet Cardiovase Diagn. 1997; 40: 173-175
        • Bacharach JM
        • Garratt KN
        • Rooke TW
        Chronic traumatic thoracic aneurysm: report of two cases with the question of timing for surgical intervention, y.
        Vasc Surg. 1993; 17: 780-783
        • Parmley LF
        • Maltingly TW
        • Manion WC
        • Jahnke Jr, FJ
        Non-penetrating traumatic injury of the aorta.
        Circulation. 1958; 17: 1086-1101
        • Prater SP
        • Leya FS
        • McKiernan TL
        Post-traumatic pseudo-aneurysm of the ascending aorta-an incidental finding two decades later.
        Clin Cardiot. 1994; 17: 566-568
        • Olsen J
        Aneurysm of the aortic sinus of Valsalva: a case of rupture and myocardial infarction.
        Acta Pathol Microbiol Scand. 1969; 76: 12-18
        • Boutefeu JM
        • Moret PR
        • Hahn C
        • Häuf E
        Ancurysms of the sinus of Valsalva: report of seven cases and review of the literature.
        Am J Med. 1978; 65: 18-24
        • Bayada JM
        • Giordano P
        • Corncil G
        • Gibelin P
        • Jourdan J
        • Morand P
        Compression of the coronary trunk by aneurysm of the antero-left Valsalva sinus associated with acute mitral insufficiency caused by rupture of the chordae following valvular prolapse: successful triple surgical operation in a 66-year old patient [in French].
        Ann Cardiol Angeiol (Paris). 1993; 42: 305-307
        • Brandt J
        • Jogi P
        • Luhrs C
        Sinus of Valsalva aneurysm obstructing coronary arterial flow: case report and collective review of the literature.
        Eur Heart J. 1985; 6: 1069-1073
        • Koike S
        • Takayama S
        • Furihata A
        • et al.
        Infective endocarditis causing acute myocardial infarction by compression of the proximal left coronary artery due to a mycotic aneurysm of the sinus of Valsalva.
        Jpn Circ J. 1991; 55: 1228-1232
        • Matsumoto Y
        • Kubo T
        • Tagawa H
        • et al.
        An autopsy case of the sinus of Valsalva aneurysm involved with tuberculous inflammation, leading to complete heart block [in Japanese].
        Kokyu To Junlcan. 1993; 41: 911-915
        • Chipps HD
        Aneurysm of sinus of Valsalva causing coronary occlusion.
        Arch Pathol. 1941; 31: 627-630
        • Kieffer E
        • Chiche L
        • Bertal A
        • Bahnini A
        • Koskas F
        Inflammatory ancurysms of the thoracic aorta: surgical aspects [in French].
        Arch Mal Coeur Vaiss. 1997; 90: 1751-1758
        • Ishikawa K
        Diagnostic approach and proposed criteria for the clinical diagnosis of Takayasu's arteriopathy.
        J Am Colt Cardiol. 1988; 12: 964-972
        • Amano J
        • Suzuki A
        Coronary artery involvement in Takayasu's arteritis: collective review and guideline for surgical treatment.
        J Thorac Cardiovasc Surg. 1991; 102: 554-560
        • Sharma S
        • Rajani M
        • Kamalakar T
        • Kumar A
        • Talwar KK
        The association between aneurysm formation and systemic hypertension in Takayasu's arteritis.
        Clin Radiol. 1990; 42: 182-187
        • Nakano T
        • Okano H
        • Konishi T
        • Takczawa H
        Aneurysm of the left aortic sinus caused by Takayasu's arteritis: compression of the left coronary artery producing coronary insufficiency.
        J Am Coll Cardiol. 1986; 7: 696-700
        • Evans JM
        • Bowles CA
        • Bjomsson J
        • Mullany CJ
        • Hunder GG
        Thoracic aortic aneurysm and rupture in giant cell arteritis: a descriptive study of 41 cases.
        Arthritis Rheum. 1994; 37: 1539-1547
        • Klein RG
        • Hunder GG
        • Stanson AW
        • Sheps SG
        Large artery involvement in giant cell (temporal) arteritis.
        Ann Intern Med. 1975; 83: 806-812
        • Gravallese EM
        • Corson JM
        • Coblyn JS
        • Pinkus GS
        • Weinblalt ME
        Rheumatoid aortitis; a rarely recognized but clinically significant entity.
        Medicine (Baltimore). 1989; 68: 95-106
        • Roguin A
        • Edoute Y
        • Milo S
        • Shtiwi S
        • Markiewicz W
        • Reisner SA
        A fatal case of Behcet' s disease associated with multiple cardiovascular lesions.
        Int J Cardiol. 1997; 59: 267-273
        • Freyrie A
        • Paragona U
        • Cenacchi G
        • Pasquinelli G
        • Guiducci G
        • Faggioli GL
        True and false aneurysms in Behçcl's disease: case report with ultrastructural observations.
        J Vasc Surg. 1993; 17: 762-767
        • Ferrari E
        • Taillan B
        • Gamier G
        • Dor V
        • Morand P
        • Dujardin P
        Cardiovascular manifestations of Cogan syndrome: apropos of a case [in French].
        Arch Mal Coeur Vaiss. 1992; 85: 913-916
        • Cipriano PR
        • Alonso DR
        • Baitaxe HA
        • Gay Jr, WA
        • Smith JP
        Multiple aortic aneurysms in relapsing polychondritis.
        Am J Cardiol. 1976; 37: 1097-1102