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Multiple giant saccular aneurysms in coronary circulation

Dharmesh R Mehta¹, Nishith K Singh¹, Tony J DeMartini², John E Murphy³

¹ Maricopa Medical Center, Internal medicine, Phoenix, Arizona, 85044, USA
² Southern Illinois University School of Medicine, Internal Medicine, Springfield, Illinois, 62704, USA
³ Memorial Medical Center, Southern Illinois University School of Medicine, Department of Pathology, Springfield, Illinois, 62781, USA

Correspondence to:
nishith_singh2007{at}yahoo.com

A 69-year-old hypertensive male smoker presented with acute inferior wall myocardial infarction. Cardiac catheterisation exposed an aneurysmal right coronary artery (RCA) with occluded lumen and an ectatic proximal left anterior descending artery (LAD). Chest computed tomography (fig 1) revealed a large calcified aneurysm with intraluminal thrombus. He underwent RCA bypass, but expired on the second day of surgery due to arterial suture dehiscence and haemorrhage. At autopsy the LAD had a proximal aneurysm (2.5 cm) and the RCA was found to have six discrete large saccular aneurysms (6, 2.2, 3, 6, 5 and 3.5 cm) (fig 2 shows two proximal aneurysms, arrow pointing to unaffected artery segment). RCA wall microscopy (fig 3) was suggestive of severe calcific atherosclerosis with few acute inflammatory cells related to surgery.

View this figure (120K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Computed tomography of chest showing a large (6 cm, arrow) proximal right coronary aneurysm with wall calcification and thrombosed lumen.

 

View this figure (169K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Gross specimen showing large right coronary proximal aneurysms (cut open longitudinally) and compared to the intervening normal segment(arrow).

 

View this figure (192K): in this window | in a new window | PowerPoint for Teaching   Figure 3 Cross sectional microscopy of aneurysm wall showing severe calcific deposits in media and few acute inflammatory cells in outer layers (left lower quadrant of image) related to surgery.

 

By definition coronary artery aneurysms (CAAs) are aneurysmal dilatation >1.5 times the adjacent normal coronary segment. They are commonly related to an underlying atherosclerotic disease but higher prevalence has also been found in patients with Kawasaki’s disease, arteritis, mycoses, chest trauma, connective tissue disorders (Marfan’s and Ehlers–Danlos syndromes), metastatic tumours, polycystic kidney disease, percutaneous coronary interventions, idiopathic hypereosinophilic syndrome, coronary artery angiodysplasia and cocaine use.^1–3 The reported incidence varies from 0.2–5.3%.³ Large CAAs of 5 cm in adults unrelated to Kawasaki’s disease are extremely rare. Our case is the first report of such large saccular coronary aneurysms occurring at multiple sites along the vessel. Most patients with CAA are asymptomatic but may present with vasospasm, rupture, angina, myocardial infarction or stroke.³ Data on long term prognosis and optimal management is lacking yet most agree that coronary artery bypass surgery be performed in symptomatic patients.³

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication

1. Satran, A, Bart, BA, Henry, CR, et al. Increased prevalence of coronary artery aneurysms among cocaine users. Circulation 2005; 111: 2424–9.[Abstract/Free Full Text]
2. Banaerjee, P, Houghton, T, Walters, M, et al. Giant right coronary artery aneurysm presenting as a mediastinal mass. Heart 2004; 90: e50.[Abstract/Free Full Text]
3. Syed, M, & Lesch, M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis 1997; 40: 77–84.[CrossRef][Medline]

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