Surgical Innovations in Treating Coronary Artery Aneurysms: A Case Study

In early 2024, a 61-year-old male physician sought treatment at the Cleveland Clinic for a right coronary artery aneurysm (CAA) complicated by a fistula to the coronary sinus. Despite displaying minimal symptoms, imaging conducted since 2022 indicated dilation of the right ventricle, prompting the patient to explore surgical options after conservative management yielded no improvement. This case highlights both the complexities of diagnosing and treating CAAs and the innovative surgical techniques developed at the Cleveland Clinic.

Coronary artery aneurysms are relatively rare, occurring in approximately 0.3% to 5.3% of the population, with a notable prevalence among male patients. According to Dr. Nicholas Ruthmann, a cardiologist at Cleveland Clinic, about 50% of patients with CAA also present with coronary artery disease (CAD), often complicating the clinical picture. The patient’s situation was further complicated by moderate CAD identified during a catheterization in 2023, which highlighted the need for careful monitoring and management of his condition.

Upon evaluation, Dr. Ruthmann and Dr. Faisal Bakaeen, a cardiothoracic surgeon at Cleveland Clinic, confirmed the presence of a 1.5 cm CAA. Nuclear imaging tests revealed mild ischemia in the right ventricle, raising concerns that the aneurysm could worsen the patient’s condition due to increased loading conditions from the fistula. This raised the necessity for surgical intervention, particularly as the patient's left ventricular ejection fraction had decreased to 50%, indicating significant cardiac strain.

Initial treatment involved anticoagulation therapy with warfarin to mitigate the risk of thrombus formation. When the patient’s symptoms progressed—marked by fatigue and shortness of breath—he decided to pursue surgical options. In late summer 2024, Dr. Bakaeen performed an innovative surgical procedure to repair the aneurysm and address the fistula. This technique, which was detailed in a seven-patient case series published in the *Journal of the American College of Cardiology: Case Reports* (2022;4:101665), involved the oversewing of the proximal right coronary artery and the creation of bypasses using a harvested saphenous vein, ensuring adequate blood supply to the heart's right side.

The surgery proved successful, with the patient experiencing an unremarkable recovery. He was discharged six days post-operation and resumed his medical practice, reporting a significant improvement in his energy levels and overall health. This outcome underscores the importance of timely surgical intervention in patients with symptomatic CAAs and the potential for innovative surgical techniques to provide effective treatment.

Dr. Bakaeen emphasizes that while some centers may opt for catheter-based approaches to address the fistula, the complexities involved often necessitate surgical solutions. Surgical repair not only eliminates the aneurysm but also reduces the risk of clot formation and potential ruptures. A retrospective review of 458 patients treated for CAAs at Cleveland Clinic demonstrated that surgical interventions yield favorable long-term outcomes, reinforcing the need for specialized care in these complex cases.

This case illustrates the intersection of advanced surgical techniques and the management of rare cardiac conditions, highlighting the Cleveland Clinic's commitment to pioneering treatment options for challenging diagnoses. As more patients present with similar complexities, ongoing research and innovation in the field of cardiovascular surgery will be paramount in improving patient outcomes and expanding treatment options for coronary artery disease and aneurysm management.