PMC6712981_01
Emergent coronary angiography demonstrated occlusion of the proximal left anterior descending artery (LAD) inside the aneurysm (A). The balloon inflation clearly revealed the distal funnel of the aneurysm: there was a 20  angle (arrow) between the intra-aneurysm portion and the extra-aneurysm portion of the balloon inside the LAD (B). Primary angioplasty at the site of occlusion restored Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow into the distal LAD (C). Six days later, a repeat coronary angiography confirmed partial regression of the thrombus in a patent LAD with TIMI grade 3 flow (D, E, F). Then, the Heart Team decision was to proceed with cardiothoracic surgery combining aneurysm exclusion and coronary artery bypass graft. During surgery the aneurysm was opened showing residual thrombus inside (arrowhead; G, H). Control coronary angiography revealed a total exclusion of the aneurysm (I) and final good result of the left internal mammary artery bypass grafting (J).
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LAD inside the aneurysm (Fig. 1A). Left ventriculography showed a new, severely reduced ejection fraction (calculated LVEF of 28%) with marked hypokinesis of the anterior segments. Of note, during coronary balloon inflation the distal funnel of the aneurysm was exposed, with a calculated 20  angle between the intra- and extra-aneurysm portions of the balloon inside the LAD (Fig. 1B, C). TIMI grade 3 flow (Fig. 1D-F). The maximal diameter of the aneurysm exceeded 15.0 mm associated with a sac length of 60 mm by intravascular ultrasound imaging. Intraprocedurally, the LAD coronary aneurysm (Fig. 1G, H) was released after transection of the pulmonary artery. Control coronary angiography revealed a total exclusion of the aneurysm (Fig. 1I) and good result of the LIMA bypass grafting (Fig. 1J).