Abstract
Background
Giant coronary aneurysms are rare and may present with acute myocardial infarction, posing significant diagnostic and therapeutic challenges.
Case Summary
We report the case of a 45-year-old woman residing in a high-altitude region who presented with anterior ST-segment elevation myocardial infarction. Initial management included thrombolysis and transfer for rescue angiography, which revealed a giant fusiform aneurysm of the left main coronary artery with thrombotic occlusion of the proximal left anterior descending artery. Additional aneurysms and ectasia were identified in other coronary vessels. Computed tomography confirmed the findings. Surgical resection and revascularization were proposed but were declined by her. She died 6 months later, likely from cardiac causes.
Discussion
This case illustrates the importance of multimodality imaging in characterizing giant coronary aneurysms and highlights the complexity of tailoring management strategies in rare, high-risk presentations.
Take-Home Message
Multimodality imaging is essential for diagnosis and treatment planning, and management should be individualized through a multidisciplinary approach.
Key Words: acute coronary syndrome, computed tomography, thrombosis
Graphical Abstract
History of Presentation
A 45-year-old woman presented to the emergency department with a 2-hour history of sudden-onset, oppressive chest pain rated 9/10 on the pain scale, radiating to the left arm and accompanied by dyspnea. On examination, her blood pressure was 145/90 mm Hg, heart rate 113 beats/min, respiratory rate 24 breaths/min, and room air oxygen saturation 88%. No peripheral edema, cyanosis, or jugular venous distention was observed. Pulmonary auscultation revealed bilateral crackles at the lung bases, whereas cardiac auscultation showed regular heart sounds without murmurs.
Take-Home Messages
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Giant left main coronary artery aneurysms are exceptionally rare and may manifest as ST-segment elevation myocardial infarction.
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This highlights the importance of early multimodality imaging for guiding diagnosis and management.
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Management should be individualized, integrating surgical, percutaneous, and medical strategies within a multidisciplinary approach.
Past Medical History
The patient was a native and lifelong resident of Puno, Peru, located at 3,827 m above sea level in the Andean region. She had a history of hypertension diagnosed 2 years ago and class II obesity (body mass index: 38.5 kg/m2). She denied dyspnea, exertional angina, family history of cardiovascular disease, or use of alcohol or psychoactive substances.
Differential Diagnosis
The patient's clinical presentation was consistent with acute coronary syndrome. Differential diagnoses included coronary occlusion, coronary spasm, coronary dissection, myocarditis, acute pericarditis, aortic dissection, and pulmonary thromboembolism, particularly in the context of obesity and high altitude. The absence of previous cardiovascular symptoms reduced the likelihood of chronic structural heart disease.
Investigations
The admission electrocardiogram revealed a sinus rhythm with ST-segment elevation in leads V2 to V5, I, and aVL, accompanied by reciprocal ST-segment depression in the inferior leads (Figure 1A). Initial troponin T levels were 2.34 ng/mL (reference range: 0-0.014 ng/mL), the hemoglobin level was 19.1 g/dL, and the arterial lactate level was 1.4 mmol/L. Renal and hepatic function were preserved, and the coagulation profile showed no abnormalities. Transthoracic echocardiography revealed a reduced left ventricular ejection fraction of 40%, with hypokinesia of the anterior and anteroseptal walls. No evidence of mechanical complications was observed.
Figure 1.
Electrocardiogram and Coronary Angiography Findings
(A) ECG showing ST-segment elevation in leads V2 to V5, I, and aVL, with reciprocal ST-segment depression in leads II, III, and aVF. (B) Right caudal view showing a giant LMCA aneurysm with circumflex ectasia. (C) Left caudal view revealing thrombotic occlusion of the proximal LAD (green asterisk). (D) Left cranial view confirming proximal LAD occlusion (green asterisk). ECG = electrocardiogram; LAD = left anterior descending artery; LMCA = left main coronary artery.
The patient presented with anterior ST-segment elevation myocardial infarction, classified as Killip-Kimball class II, at a non–percutaneous coronary intervention center. Pharmacological reperfusion therapy with alteplase was initiated. The patient was subsequently transferred to our center for rescue percutaneous coronary intervention.
Coronary angiography revealed a giant aneurysm of the left main coronary artery with significant thrombotic burden, a fusiform aneurysm of the left anterior descending artery, and thrombotic occlusion in its proximal segment (Figures 1B and 1D, Video 1). The circumflex artery exhibited signs of ectasia (Video 2). Angioplasty was not performed.
Coronary computed tomography angiography (CCTA) revealed a 22 × 23 mm giant fusiform aneurysm in the left main coronary artery (Figures 2A and 2B), along with a 15 × 15 mm aneurysm and thrombotic occlusion in the proximal left anterior descending artery (Figure 2C). Furthermore, a 9 × 9 mm fusiform aneurysm was identified in the circumflex artery, whereas the proximal and middle segments of the right coronary artery exhibited substantial ectasia (Figure 2A, Video 3).
Figure 2.
Cardiac Computed Tomography Findings
(A) Three-dimensional volume-rendered reconstruction showing a giant LMCA aneurysm (yellow asterisk), along with fusiform aneurysms of the right coronary and circumflex arteries. (B) Axial view demonstrating the LMCA aneurysm and its transverse diameter. (C) Straightened multiplanar reconstruction of the LAD showing a proximal aneurysm with intraluminal thrombus causing complete luminal occlusion. LAD = left anterior descending artery; LMCA = left main coronary artery.
Management
The patient received dual antiplatelet therapy, anticoagulation, and diuretic agents. She remained free of angina and signs of congestion. The heart team decided to proceed with the scheduled surgical procedure, which included aneurysm resection and coronary revascularization.
Follow-Up
The patient declined surgical intervention and was discharged on oral anticoagulation, beta-blockers, and angiotensin-converting enzyme inhibitors, with outpatient follow-up scheduled. Six months later, she collapsed and was brought to the hospital in cardiac arrest. She died shortly thereafter. No autopsy was performed, but the presentation was most consistent with sudden cardiac death of probable arrhythmic or ischemic origin related to her underlying coronary aneurysmal disease.
Discussion
Coronary artery aneurysms (CAAs) are focal dilations of the coronary arteries that exceed the diameter of the adjacent normal segment by at least 1.5 times. Giant aneurysms, defined as those with a diameter of >20 mm, are associated with an increased risk of thrombosis, rupture, and adverse cardiovascular events.1 CAAs are a rare entity, with an angiographic prevalence reported to be as high as 5% in some studies.2
Atherosclerosis is the most common cause of CAAs in adults, accounting for up to 50% of cases.3 In pediatric patients, Kawasaki disease is the leading cause, followed by Takayasu arteritis.4 In our patient, there were no clinical, laboratory, or imaging findings suggestive of either condition; acute phase reactants were normal, and coronary angiography demonstrated no large vessel involvement beyond the coronary arteries. She was a native and lifelong resident of Puno, Peru. Although giant CAAs are rare, studies from high-altitude regions, including Peru, have reported an increased prevalence of coronary ectasia associated with acute coronary syndromes.5 Chronic hypoxia, oxidative stress, and polycythemia may promote endothelial dysfunction and vascular remodeling, potentially contributing to aneurysm formation as an adaptive response to hypoxic stress.6 Increased blood viscosity from erythropoiesis may also have added to the thrombotic burden observed in this case.
CCTA is a key tool for evaluating CAAs, providing high-resolution imaging that enables precise characterization of vascular anatomy.7 CCTA allows for detailed assessment of aneurysm size, morphology, and extension, as well as the detection of thrombi, calcifications, and signs of dissection or impending rupture, improving both therapeutic planning and long-term follow-up.8
The approach to CAAs should be individualized on a case-by-case basis. Therapeutic decisions depend on clinical presentation, aneurysm characteristics, patient profile, and the experience of the medical team.1 In patients with coronary aneurysm and ST-segment elevation myocardial infarction, the primary goal is to restore coronary flow. Medical management with antiplatelet and anticoagulant therapy is essential to reduce the risk of recurrent thrombosis and rupture.
Coronary angioplasty with covered stents is typically reserved for relatively localized and moderately sized aneurysms, particularly when a significant coexisting stenosis causes ischemia. The interventional treatment of coronary aneurysms with drug-eluting stents has shown mixed outcomes. Patients treated with drug-eluting stents have exhibited a higher incidence of stent thrombosis and the need for repeat revascularization, highlighting the therapeutic challenge in these cases.9 Surgery is reserved for cases in which the benefit clearly outweighs the risk, typically for large or complex aneurysms not amenable to percutaneous treatment.1
The long-term prognosis of CAAs is unfavorable, with a reported mortality rate of 21.9%.10 Underlying obstructive coronary artery disease, diabetes, renal insufficiency, and ventricular dysfunction have been identified as independent predictors of adverse events.
Conclusions
CAAs present a rare clinical challenge. Continued data collection through registries and observational studies will help refine recommendations and improve the prognosis of this complex condition in the future.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Coronary Angiography of the Left System Showing a Giant LMCA Aneurysm With Thrombotic Occlusion of the Proximal LAD
LAD = left anterior descending artery; LMCA = left main coronary artery.
Coronary Angiography Confirming a Fusiform Aneurysm of the LAD and Ectasia of the Circumflex Artery
LAD = left anterior descending artery.
Coronary Computed Tomography Angiography With 3-Dimensional Reconstruction Showing Diffuse Aneurysmal Dilatation of Coronary Arteries and Their Spatial Relation to Cardiac Structures
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Associated Data
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Supplementary Materials
Coronary Angiography of the Left System Showing a Giant LMCA Aneurysm With Thrombotic Occlusion of the Proximal LAD
LAD = left anterior descending artery; LMCA = left main coronary artery.
Coronary Angiography Confirming a Fusiform Aneurysm of the LAD and Ectasia of the Circumflex Artery
LAD = left anterior descending artery.
Coronary Computed Tomography Angiography With 3-Dimensional Reconstruction Showing Diffuse Aneurysmal Dilatation of Coronary Arteries and Their Spatial Relation to Cardiac Structures