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An asymptomatic 84-year-old man was referred for cardiology assessment in view of incidental radiology findings. He had coronary artery bypass grafting in 1982 with vein grafts to the right coronary artery and left anterior descending artery (LAD). Angiography in 2000 for recurrent angina demonstrated severe native disease, patent LAD graft and occluded right coronary artery graft. He underwent uncomplicated PCI to the native right and circumflex arteries with drug eluting stents. He had rate-controlled atrial fibrillation and hypertension.
Echocardiography showed normal ventricular function, the only abnormalities were biatrial dilatation and mild aortic regurgitation. A chest roentgenogram showed ectasia of the thoracic aorta and a 7.7 cm left hilar mass (figure 1). Subsequent CT revealed a giant aneurysm (7.5×6.8 cm) arising from native LAD containing mural thrombus (figure 2). Following multidisciplinary team discussion the patient was managed conservatively, including oral anticoagulation (INR 2.0–3.0).
Coronary artery aneurysms are rare with a reported incidence ranging between 0.15–4.9%, while giant coronary artery aneurysms (diameter >20 mm) are even rarer.1 Aetiology includes Kawasaki disease, coronary atherosclerosis, connective tissue diseases, trauma (including coronary angioplasty) and syphilis.1 Complications of coronary aneurysms include distal embolisation causing myocardial infarction and spontaneous rupture. Most cases can be safely managed conservatively, however some recommend surgical intervention for all aneurysms >30 mm.1 Alternative treatment is polytetrafluoroethylene-covered stent across the origin of the aneurysm.2 Anticoagulation and antiplatelet therapy are effective in coronary aneurysms due to Kawasaki's, however the benefit of warfarin over antiplatelet therapy in atherosclerotic aneurysms is less clear.
Contributors AW and JRW contributed equally in all aspects of the preparation and authorship of the manuscript.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
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