Ann Thorac Surg 2007;84:1740-1742. doi:10.1016/j.athoracsur.2007.05.006
© 2007 The Society of Thoracic Surgeons
Case Reports
Giant Right Coronary Artery Aneurysm
Robert Blank, MDa,*,
Philipp K. Haager, MDa,
Micha Maeder, MDa,
Michele Genoni, MDb,
Hans Rickli, MDa
a Division of Cardiology, Department of Internal Medicine, Kantonsspital St. Gallen, Zurich, Switzerland
b Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Accepted for publication May 4, 2007.
* Address correspondence to Dr Blank, Division of Cardiology, University Hospital Basel, Petersgraben 4, Basel, CH-4031, Switzerland (Email: rblank{at}uhbs.ch).
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Abstract
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We report the case of a 59-year-old man with a giant atherosclerotic thrombus-filled aneurysm of the right coronary artery presenting as an ambiguous spherical mass adjacent to the right atrium at the transthoracic echocardiography study. The diagnosis was established by transesophageal echocardiography, computed tomography, and coronary angiography. Due to extent of the aneurysm, the patient underwent placement of a vein graft to the posterior descending artery and subsequent exclusion of the aneurysm by proximal and distal ligation.
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Introduction
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Coronary artery aneurysm is a rare abnormality and may result from congenital or acquired conditions [1]. The optimal management is ill defined. We herein present the case of a huge asymptomatic aneurysm of the right coronary artery.
In August 2005, a 59-year-old man with a history of peripheral arterial occlusive disease and aneurysm of the left femoral artery and bilateral popliteal aneurysms was referred for routine echocardiography. Seven years ago, 6 months after renal transplantation for chronic glomerulonephritis, he had suffered a myocardial infarction. At that time, coronary angiography had revealed a dilated form of coronary artery disease without significant stenoses.
Transthoracic echocardiography disclosed an equivocal spherical mass (4.5 x 3.6 cm) adjacent to the wall of right atrial wall. The mass was best seen in the apical four-chamber view (Fig 1). The electrocardiogram revealed an old inferior myocardial infarction. A chest roentgenogram demonstrated a calcified mass in projection of the right atrium. Transesophageal echocardiogram showed a mass between the right heart chambers and the sternum (diameter, 4 cm) with a well-delineated hyperechogenic external border and a small echo-free space. Pulsed-waved Doppler (Multigon, Yonkers, NY) demonstrated diastolic flow within the mass. The patient underwent computed tomography, and the mass was identified as a huge aneurysm of the right coronary artery (5.6 x 4.7 x 8 cm) filled with thrombus (Fig 2). Coronary angiography showed a 70% stenosis of the proximal right coronary artery and confirmed the presence of a large aneurysm of the mid right coronary artery (Fig 3). Otherwise there were no relevant coronary stenoses. Magnetic resonance imaging of the brain excluded intracranial aneurysms, and screening for vasculitis provided negative results. Given the extent of the aneurysm and the need for peripheral vascular surgery, the patient was referred for cardiac surgery (Fig 4). A vein graft was placed to the posterior descending artery, and thereafter the aneurysm was ligated proximally and distally but not resected. The right mammarian artery could not be used as a graft as it was too short, but a biopsy specimen was obtained, showing mild myxoid degeneration.
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Fig 1. Apical four-chamber view showing a spherical mass (4.5 x 3.6 cm, arrow) adjacent to the right atrial wall.
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Fig 2. Cardiac computed tomographic scan (three-dimensional reconstruction) showing the aneurysmatic dilation of the right coronary artery (arrow).
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Comment
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Coronary aneurysms are most often atherosclerotic in origin, as with the present patient. An important form of nonatherosclerotic coronary aneurysm is Kawasaki’s disease, which usually occurs in childhood as an acute disease [1]. Other underlying conditions include connective tissue diseases, cocaine abuse [2], or trauma [3].
The majority of patients are asymptomatic, and the aneurysms are found incidentally during angiography. However, slow flow within the aneurysm may lead to thrombus formation with vessel occlusion and myocardial infarction [4]. Other rare presentations include acute rupture with hemopericardium and tamponade or compression of the adjacent cardiac chambers, requiring prompt surgical intervention [5].
Due to their rare occurrence the best management of coronary aneurysms is ill defined. In asymptomatic patients, surgery is recommended by some authors if the diameter of the aneurysm exceeds at least three to four times the size of the original vessel diameter [6], but most authors recommend surgery based on the severity of associated coronary stenosis [7].
The prognosis of coronary artery aneurysm depends on the presence and severity of concomitant obstructive coronary artery disease.
Echocardiography allows a conclusive diagnosis of giant coronary aneurysm [8]. In addition, angiography is required to assess the presence and extent of coronary artery disease and to plan further investigation and intervention. Giant coronary artery aneurysms remain a rare pathology, and their management should be individualized depending on size, location, and clinical context.
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References
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- Banerjee P, Houghton T, Walters M, Kaye GC. Giant right coronary artery aneurysm presenting as a mediastinal mass Heart 2004;90:e50.[Abstract/Free Full Text]
- Satran A, Bart BA, Henry CR, et al. Increased prevalence of coronary artery aneurysms among cocaine users Circulation 2005;111:2424-2429.[Abstract/Free Full Text]
- Wan S, Le Clerc JL, Vachiery JL, Vincent JL. Cardiac tamponade due to spontaneous rupture of right coronary artery aneurysm Ann Thorac Surg 1996;62:575-576.[Abstract/Free Full Text]
- Chia HMY, Tan KH, Jackson G. Non-atherosclerotic coronary artery aneurysms: two case reports Heart 1997;78:613-616.[Abstract/Free Full Text]
- Channon KM, Banning AP, Davies CH, Bashir Y. Coronary artery aneurysm rupture mimicking dissection of the thoracic aorta Int J Cardiol 1998;65:115-117.[Medline]
- Biglioli P, Alamanni F, Antona C, Agrifoglio M, Spirito R. Aneurysms of the coronary arteries: one case report Thorac Cardiovasc Surg 1988;36:239-240.[Medline]
- Syed M, Lesch M. Coronary artery aneurysms: a review Prog Cardiovasc Dis 1997;40:77-84.[Medline]
- Tsutsui JM, Martinez EE, Rochitte CE, Ramires JF, Mathias J. Noninvasive evaluation of left circumflex coronary aneurysm by real-time three-dimensional echocardiography Eur J Echocardiography 2006;7:75-78.
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Abstract
Introduction
