Coronary artery aneurysm is a rare congenital or acquired anomaly. The commonest location
of coronary artery aneurysms is the right coronary artery and they are found slightly more often
in males. We report an unusual case of multiple and extremely large aneurysms, therefore
potentially at risk of rupture or thrombosis. (Cardiol J 2011; 18, 4: 434&#8211;436

Buszman, Paweł

Peszek-Przybyła, Ewa

Radwan, Kazimierz

Sosnowski, Maciej

English

Via Medica Journals

CASE REPORTCardiology Journal2011, Vol. 18, No. 4, pp. 434–436Copyright © 2011 Via MedicaISSN 1897–5593434 www.cardiologyjournal.orgAddress for correspondence:  Kazimierz Radwan, 3rd Coronary Care Unit, Silesian Medical Centre, ul. Ziołowa 47,40–635 Katowice, Poland, tel/fax: +48 32 252 72 12, e-mail: kradwan@neostrada.plReceived: 23.07.2009 Accepted: 14.02.2010A case of multiple giantright coronary artery aneurysmsKazimierz Radwan1, 2, Ewa Peszek-Przybyła3, Paweł Buszman1, 3, Maciej Sosnowski2, 31Coronary Care Unit, Silesian Medical Centre, Katowice, Poland2Unit of Noninvasive Cardiovascular Diagnostics, Silesian Medical Centre, Katowice, Poland33rd Chair and Division of Cardiology, Medical University of Silesia, Katowice, PolandAbstractCoronary artery aneurysm is a rare congenital or acquired anomaly. The commonest locationof coronary artery aneurysms is the right coronary artery and they are found slightly more oftenin males. We report an unusual case of multiple and extremely large aneurysms, thereforepotentially at risk of rupture or thrombosis. (Cardiol J 2011; 18, 4: 434–436)Key words: right coronary artery, coronary artery aneurysms, multipleaneurysms, multirow detector computed tomographyIntroductionCoronary artery aneurysm is a rare congenitalor acquired anomaly (Kawasaki disease or athero-sclerosis). The commonest location of coronary ar-tery aneurysms is the right coronary artery (RCA)and they are found slightly more often in males. Theaneurysms could be single or multiple, may producesymptoms or may be asymptomatic even thoughhazardous; they can cause sudden cardiac death,thrombus formation in aneurysm lumen, aneurysmrupture with vessel obstruction or embolization, oreven fistula formation [1, 2].Case descriptionA 73-year-old male, a smoker with a history ofhypertension, hyperlipidemia, gout and chronic sta-ble angina pectoris, after implantation of DDD typepacemaker and diagnosed multiple aneurysms (co-ronary arteries, abdominal aorta, iliac arteries), pre-sented with girdle chest pain radiating to right up-per arm (angina status CCS class II). The patienthad no history of injury, connective tissue disease,rheumatic fever  nor any family history of such.Laboratory exams performed on admission tothe hospital showed no abnormalities. A 12-leadelectrocardiogram (ECG) showed neutral axis, rate78 BPM, DDD stimulation.Transthoracic echocardiography revealed ejectionfraction of 45%, enlargement of left atrium (43 mm,area 22 cm2) and right ventricle (28 mm), mitral andtricuspid insufficiency (grade I) and presence ofelectrode in right ventricle. Coronary angiogramsrevealed ‘cloudy’ areas with blurred borders, whichsuggested the presence of RCA aneurysms (Fig. 1).Multi-slice computed tomography (64-detectorrow MSCT) performed using Toshiba Aquilion 64,showed Calcium score of 7,049 Agatston units, in-tramural calcifications within RCA and three visi-ble RCA aneurysms: proximal (diameter 40 mm),medial (32 mm) and last one (82 mm) compressingthe right atrium, right ventricle, superior and infe-rior vena cava. The aneurysms were lined withmural thrombi (Fig. 2–4). Left main artery widthwas 10 mm with calcifications resulting in diame-ter stenosis about 30%. Left anterior descendingartery was dilated up to 14 mm in segment 7, othersegments presented massive calcifications andmultilevel stenoses up to 60%. Circumflex artery435Kazimierz Radwan et al., A case of multiple giant RCA aneurysmswww.cardiologyjournal.orgwas narrow, with insignificant stenoses. Marginalbranch artery diameter was 5 mm with multiplemixed plaques causing stenoses up to 40%.The patient was successfully operated uponusing standard anesthetic techniques, througha median sternotomy, with standard cardiopulmo-nary bypass and 28°C systemic hypothermia withcardioplegia. The right coronary artery aneurysmswere excised and RCA was underpinned. In thecourse of post-operative treatment, the patient re-quired administration of catecholamines and in-traaortic balloon pump. This procedure could beperformed because of the exact visualization of theaneurysms in computed tomography.Figure 1. Invasive coronary angiography of right coro-nary artery demonstrating two aneurysms; the third,giant, one is not visible.Figure 2. Axial-section computed tomography demon-strating right coronary artery origin with proximal aneu-rysm (diameter 40.4 mm). A second moderate aneu-rysm is visible.Figure 4. Three-dimensional heart reconstruction: cle-arly visible are two right coronary artery aneurysms,the third giant aneurysm is less contrasted.Figure 3. Axial-section computed tomography — rightcoronary artery aneurysm (dimensions 72.3 × 84.2 mm)with intramural thrombi.40.4 mm72.3 mm84.2 mm436Cardiology Journal 2011, Vol. 18, No. 4www.cardiologyjournal.orgDiscussionSmall atherosclerotic coronary artery aneu-rysms are a relatively frequent finding at angiogra-phy. We report an unusual case of multiple, andextremely large, aneurysms,  therefore potentiallyat risk of rupture or thrombosis. Only such aneu-rysms are an indication for surgery. In older pa-tients, such aneurysms are usually caused byatherosclerosis, but they may be a consequence ofcoronary artery intervention, inflammation (systemiclupus erythematosus, polyarteritis nodosa, Takaya-su’s arteritis, Marfan’s syndrome, Ehlers-Danlossyndrome, Lyme borreliosis, syphilis) or congen-tial fistula. In Asia, such aneurysms are mostlycaused by Kawasaki disease [2–4].Our patient had definitely generalized athero-matous disease in his coronary arteries, suggestingthat his aneurysms had an atheromatous cause(there was no history to suggest Kawasaki diseaseor other inflammatory diseases).Invasive imaging with coronary angiographysuggested the diagnosis, but was not diagnostic. Thediagnostic test was the MSCT revealing the accu-rate anatomy, size and position of aneurysms, whichwas helpful during defining the range of surgicalprocedure.The best management strategy for coronaryartery aneurysms has not been established. It isrecommended that patients be managed individu-ally according to the location of the aneurysm andthe clinical context [1–4].We preferred the surgical option, since thepatient was symptomatic and there were multi-ple and giant aneurysms. With such aneurysms,there is a risk of rupture or myocardial ischemiadue to mural thrombi and the possibility of distalembolization.Several cases of coronary artery aneurysmhave been described. Our case is rare and interest-ing because of its multiplicity and extremely largesize. MSCT coronary angiograms should be consi-dered as a basic diagnostic tool in cases of coronaryartery aneurysm.ConclusionsMSCT coronary angiography represents anideal, non-invasive imaging modality for the diag-nosis of coronary arteries malformations, comple-menting invasive coronary imaging. Its use in themanagement algorithm should be considered.AcknowledgementsThe authors do not report any conflict of inte-rest regarding this work.References1. Everett M, Holper E, Lang R. Giant coronary aneurysm. AmJ Geriat Cardiol, 2006; 15: 394–395.2. Luz A, Silveira J, Carvahlo H, Gomes L. Right coronary arteryaneurysm. Intern J Cardiol, 2006; 114: e122–e123.3. Banerjee P, Houghton T, Walters M, Kaye GC. Giant right coro-nary artery aneurysm presenting as a mediastinal mass. Heart,2004; 90: e50.4. Manghat NE, Morgan-Hughes GJ, Cox ID, Roobottom CA. Giantcoronary artery aneurysm secondary to Kawasaki disease: Diag-nosis in an adult by multi-detector row CT coronary angiogra-phy. Br J Radiol, 2006; 79: e133–e136.

A case of multiple giant right coronary artery aneurysms

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A case of multiple giant right coronary artery aneurysms

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