# Unlocking the sealed entrance—exploring left coronary treatment options: a case report

## TL;DR

A rare case of left main coronary artery atresia was successfully treated with a novel surgical reconstruction using an external iliac artery autograft.

## Contribution

This is the first reported use of an external iliac artery autograft for surgical reconstruction of left main coronary artery atresia.

## Key findings

- The patient recovered uneventfully after the surgical reconstruction and remained stable under medical therapy.
- Stress testing showed no ischaemia despite confirmed LMCA atresia, highlighting its limited predictive value in congenital anomalies.
- The case suggests that reconstruction may be preferable to conventional bypass surgery in cases with competitive native flow.

## Abstract

Left main coronary artery (LMCA) atresia is a rare anomaly characterized by the absence of the left coronary ostium, a blind-ending left main trunk, and retrograde collateral flow from the right coronary artery. Clinical manifestations may include angina, syncope, dyspnoea, sudden death, or failure to thrive. Information on the treatment of this anomaly is extremely limited, and the long-term outcomes of conventional coronary artery bypass grafting in young patients remain uncertain.

A 37-year-old woman presented with recurrent syncope during adolescence and later developed chest pain and cardiac arrest during childbirth. Coronary angiography confirmed LMCA atresia, yet repeated stress perfusion tests consistently showed no ischaemia. Considering the limited negative predictive value of stress testing and insights from guidelines addressing other congenital coronary anomalies, surgical reconstruction was performed using an external iliac artery (EIA) autograft directly anastomosed from the aorta to the LMCA. The harvest site was repaired with a vascular prosthesis. The patient recovered uneventfully and has remained stable under medical therapy.

This case represents the first reported surgical reconstruction of LMCA atresia using an EIA autograft. It highlights the limitations of ischaemia testing in congenital coronary anomalies, the potential advantages of reconstruction over conventional bypass surgery in the setting of competitive native flow, and the importance of individualized, thoughtful decision-making. External iliac artery autograft reconstruction may offer a promising alternative for patients with this rare condition.