A Patient With a Giant Coronary Artery Aneurysm

Jul 20, 2015   |  Faris Khan, MD, FACC; John J Kelleman, MD, FACC; Gerald V. Naccarelli, MD, FACC; Mark Kozak, MD, FACC
Font Size
A
A
A

A 68-year-old man with previous history of hypertension and hyperlipidemia develops a sinus tachycardia after hip replacement. A computed tomography (CT) scan excludes pulmonary embolism; however, an incidental mass is detected near his right atrium. A testing cascade is launched, and echocardiography shows normal left ventricular size and function; however, the right atrium is small and is being compressed by an external mass. This is followed by a cardiac magnetic resonance (CMR) scan, which identifies a 3.4 x 3.1 cm (diameter) x 5.5 cm (length) aneurysm of the proximal right coronary artery (RCA) (Figure 1). The distal vessel is partially visualized with some smaller aneurysms. The remainder of the study is unremarkable. As his management options are being considered, catheterization is recommended to evaluate his right heart pressures and left coronary system. The right heart pressures and cardiac output are normal without evidence of left to right shunting. His right coronary artery aneurysm (CAA) is of the same dimension as previously seen on CMR. His physicians hope to advance the angioplasty wire to the distal RCA and advance a small catheter to this segment to inject contrast, but are unable to do so. Of note, the injected contrast remains accumulated into the aneurysm for several minutes (Figure 2). The left main coronary is normal, however; there is ectasia in the proximal left anterior descending (LAD) followed by 70-80% stenosis in the mid LAD that ended in a large aneurysm at a bifurcation of a diagonal branch. This aneurysm is around 1.0 cm in diameter (Figure 3). The circumflex also has proximal ectasia but no angiographic evidence of significant stenosis.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Which of the following describes the best course of treatment?

Show Answer