ANEURYSMS

[Wolfson__0]

  A 20 year-old male food service worker presented with traumatic back pain; an Xray showed mediastinal widening.  Further work-up (MRI, cath) showed a large descending thoracic aortic aneurysm, extensive abdominal aortic aneurysm, a left main coronary artery aneurysm, a small aneruysm of a lateral branch of the circumflex, and a small aneurysm of the proximal right coronary artery including the ostium.  The mitral valve, aortic valve, aortic root and ascending aorta are normal.  We also feel this is not the typical coronary artery involvement seen in Kowasaki's.  It seems to be an idiopathic medial aortopathy and arteriopathy.  Does anyone have any experience with this?  Are there any other thoughts?

[CCF Cardio MD - MTR]

_
Dear Wolfson, thank you for your question.  I surveyed my colleagues here and
noone can remember a case similar to yours.  I also performed a medline search
and found out that there is a controversy about whether to routinely perform
bypass surgery on patients with coronary aneuryms or to manage them with intensive
anticoagulation long-term.  It's interesting that the aortic valve and ascending
aorta and arch are not involved.  However, it sounds like a connective tissue
disorder is involved (like Ehler's Danlos syndrome).   I think bypass surgery
should be considered since your patient has a high risk of infarcting with
the multiple coronary aneurysms.  The ideal treatment for the descending thoracic
aortic aneurysm is more difficult to determine because of the high-risk of paraplegia from
replacement of this portion of the aorta.  I hope this information helps.