Giant coronary artery aneurysms involving all three coronary arteries

Coronary artery aneurysm is defined as any coronary artery dilation exceeding the diameter of normal adjacent segments or the diameter of the largest coronary artery by 1.5 times.¹ Giant coronary aneurysm refers to an aneurysm with a diameter of 20 mm or more.² Giant coronary artery aneurysms have an incidence of 0.02%–2%.¹ Here we describe a patient who had giant coronary aneurysms involving all three coronary arteries. He was managed conservatively with no cardiac events on a follow up of 1 year.

A 63 year old male presented to us with history of left sided shoulder pain of one day duration. The pain was persistent, radiating to the back and left hand, associated with sweating and mild dyspnea. The pain started after exertion in the form of lifting a heavy weight. There was a past history of similar episodes of shoulder pain after carrying heavy weight in the past 10yrs, disabling the patient for half an hour each time. He was an ex-smoker with no diabetes, hypertension, dyslipidemia or family history.

Examination revealed a pulse rate of 90 beats per minute, blood pressure of 100/60 mm of Hg, there was no frozen shoulder on the left side and the rest of the systemic examination was normal. His electrocardiogram revealed dynamic T inversions in V4 to V6 and troponin I was elevated (Trop I – 1.4 ng/dl, the upper limit being 0.05 ng/dl).

2D Trans thoracic Echocardiography showed normal valves with mild dilatation of aortic root (4.1 cm), no regional wall motion abnormalities and normal biventricular function with left ventricular ejection fraction of 65%. The right coronary artery (RCA) was aneurysmal at origin. The left anterior descending artery (LAD) and the left circumflex artery (LCX) were seen to be dilated in the parasternal short axis view at the level of aortic valve (Fig. 1).The left main coronary artery appeared normal.

In view of non ST elevation myocardial infarction, the patient was taken for a coronary angiogram which was done via the right radial route. There were aneurysms involving all three coronary arteries mainly involving their proximal segments. The LAD and the LCX were aneurysmal in their proximal segments but RCA was aneurysmal in its entire length (Figs. 2 and 3, Videos 1 and 2). There was a 95% stenosis of distal LCX distal to the stenosis. An aortogram was also performed which showed a normal ascending aorta, arch and descending aorta until its bifurcation into the iliac arteries. The aortic arch vessels were also normal.

Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.ihj.2014.11.003

The following are the supplementary video related to this article:

A coronary CT angiography was done in order to delineate the actual size of the aneurysm and also to look for the presence of thrombus. The CT revealed aneurysmal dilatation of LAD up to 4.3 cm in length and 1.2 cm in its widest dimension (Fig. 4). There was a fusiform aneurysm of LCX of 4.9 cm in length and 4.5 cm in its maximum dimension with mural thrombus (Fig. 4). There was a long 8.1 cm fusiform aneurysm of RCA with 1 cm width in its maximum dimension (Fig. 5).

The patient's CRP was elevated (CRP – 7.9 mg/dl) but ESR was normal (ESR – 16 mm), ANA and other autoimmune markers were negative ruling out active connective tissue disease. The rare possibility of an undetected Kawasaki disease during childhood with coronary aneurysms was entertained. The patient was advised to undergo a coronary artery bypass surgery as the distal vessels were relatively uninvolved. But as the patient opted for medical management, he was managed conservatively with dual antiplatelets, high dose statins, betablockers and ACE inhibitors. Patient had no further angina and has been on regular follow up for the past 1 year.