eComment. Evidence, experience or novelty for achieving the best outcome in surgery?

I read with great interest the article by Cuttone and colleagues [1]. They reported a unique surgical treatment strategy for the management of circumflex coronary artery aneurysm (CAA) in an adult presenting with myocardial ischaemia. Coronary artery disease (CAD) is an important etiology for CAA formation in adults; however, connective tissue disorders and Kawasaki disease may lead to multiple giant CAAs in children [2]. Although rarely encountered, the cases with CAA present with technical challenges when interventional or surgical treatment modalities are concerned. Boyer and colleagues reviewed the literature and ACC/AHA acute coronary syndrome guidelines recently and the following indications were stated as the indications for surgical revascularization in CAA: (i) CAA involving the left main coronary artery, (ii) multivessel CAD, (iii) giant CAA (the diameter of CAA exceeding the reference vessel diameter by 4 times), (iv) CAA involving bifurcation of significant sidebranch vessel and (v) other separate indications for cardiothoracic surgery unrelated to CAA [3]. The surgical indication for this case is questionable in my opinion, unless the stenotic lesion at the right coronary artery deemed a surgical revascularization necessary. When the diameter and the location of the CAA is considered, this case seems to be manageable by percutaneous intervention with regard to the abovementioned criteria. Boyer et al. also mention that surgical revascularization is considered reasonable in cases where the PTFE-coated, bare metal or drug eluting stents cannot be delivered across the lesion [3]. In this case, the CAA was demonstrated to be thrombus free, which would provide safer circumstances for a covered, bare or drug eluting stent delivery.