Abstract
Supplemental material is available for this article.
Keywords: Coronary Arteries, Aneurysms, Dissection
A 71-year-old male patient was admitted to the emergency department for nonspecific chest pain and vertigo. Troponin levels were slightly elevated. Echocardiography showed an ectatic structure containing flow into the right ventricle, and chest radiography revealed a right-sided mediastinal mass (Fig 1A, Movies 1–3). Electrocardiographically gated CT demonstrated a giant coronary aneurysm (Figs 1B and 1C) and mild to moderate atherosclerosis of the right coronary artery and left anterior descending artery. A dissection, which formed a subepicardial hematoma, extending into the right ventricle was observed (Fig 2, Movies 1–3). No other pathologic conditions were detected.
Figure 1:
Images in a 71-year-old male patient who presented with chest pain and vertigo. (A) Chest radiograph shows a cardiac shadow enlargement and a coronary aneurysm (black line), as well as a compressed and dislocated right atrium (dotted line). (B) Volume-rendered CT image depicts a giant coronary aneurysm (*) of the right coronary artery (RCA) and the origin of a dissection (DISS) (arrow). (C) Volume-rendered CT image (only showing the left ventricle and the RCA) demonstrates the giant coronary aneurysm (*) and dissection (DISS) from different angles. Ao = aorta, LV = left ventricle, PA = pulmonary artery, RV = right ventricle.
Figure 2:
(A) Axial electrocardiographically gated CT angiographic images demonstrate a giant coronary aneurysm of the dilated right coronary artery (RCA) measuring 70 × 70 mm with a 10-mm-wide dissection (DISS), forming a subepicardial hematoma, with fistula to the right ventricle (arrow). (B) Multiplanar reconstruction stretch view of the giant coronary aneurysm (*) of the RCA and the dissection (DISS) forming a subepicardial hematoma. Mild to moderate atherosclerosis was detected. Ao = aorta, LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
Movie 1:
Axial electrocardiographically gated CT stack.
Movie 2:
Three-dimensional volume-rendering technique reconstruction.
Movie 3:
Three-dimensional volume-rendering technique reconstruction shows only the left ventricle and right coronary artery.
Just before surgical treatment, the patient experienced cardiac arrest without return of spontaneous circulation.
Giant coronary aneurysms, variably defined as aneurysms with diameters ranging from 20 mm to up to four times the reference vessel diameter, are extremely rare (incidence of 0.02% in a cardiac surgical population) (1,2). The main cause of coronary aneurysms includes atherosclerosis (50% of all cases), which was the presumed cause in this case. Other causes include different forms of vasculitis such as Kawasaki disease or Takayasu arteritis, conjunctive tissue disease, infection, trauma, and percutaneous coronary interventions (2). Coronary artery dissection can develop either secondarily from coronary aneurysms, sharing risk factors and causes, or idiopathically, also known as spontaneous coronary artery dissection (3).
An important differential diagnosis to coronary artery aneurysm is coronary cameral fistula. Additionally, some patients may present with symptoms such as angina pectoris due to coronary steal phenomenon (4). Most coronary aneurysms are asymptomatic and originate from the right coronary artery. Rupture is extremely rare and has been described in only a few case reports (5). While percutaneous interventions (eg, covered stents) are therapeutic options, most patients are treated surgically (2).
Footnotes
Authors declared no funding for this work.
Disclosures of conflicts of interest: F.H. No relevant relationships. R.S. No relevant relationships. C.W. No relevant relationships. F.M.L. No relevant relationships.
Keywords: Coronary Arteries, Aneurysms, Dissection
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