|Year : 2016 | Volume
| Issue : 2 | Page : 144-147
Giant aneurysm of right coronary artery: A case report and review of literature
Biswajit Majumder, Amitava Misra, Viral Tandel, Ashfaque Ahmed
Department of Interventional Cardiology, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||4-Aug-2016|
Department of Interventional Cardiology, R. G. Kar Medical College and Hospital, Kolkata - 700 004, West Bengal
Source of Support: None, Conflict of Interest: None
Coronary artery aneurysms are seen in 1.5-5% of patients presenting for coronary angiography, but giant aneurysms, defined as being greater than 2 cm in diameter, are rare. Clinical presentation, prognosis and management of giant coronary artery aneurysm are not well defined due to limited experience, so each case is a learning tool in itself. We report the rare case of a 56-year-old female patient who presented to us with effort angina and was subsequently found to have a giant right coronary artery aneurysm with a fistulous communication to right atrium. This case describes one of the varied presentations of an ill defined and heterogeneous disease process.
Keywords: Coronary artery aneurysm, fistula, right coronary artery
|How to cite this article:|
Majumder B, Misra A, Tandel V, Ahmed A. Giant aneurysm of right coronary artery: A case report and review of literature. Nig J Cardiol 2016;13:144-7
| Introduction|| |
Both coronary artery aneurysms and fistulas are rare anomalies with the incidence of 0.5-4.9% for aneurysms on cardiac catheterization and 0.2-0.4% for fistulas. , Most are atherosclerotic in nature, but the exact mechanism leading to the development of ectasia in these vessels is unknown. Evidence suggests that contributory factors include a combination of genetic predisposition, common risk factors for coronary artery disease, direct arterial wall damage, and abnormal vessel wall metabolism. ,,, The majority of both congenital coronary artery aneurysm and fistulas originate from the right coronary artery, and >90% of fistulas drain into the right side of the heart, with the right ventricle being the most common location (~40%) followed by the right atrium and right pulmonary artery. 
In reported cases of right coronary to right atrial fistula, the connection has either been direct or through a short fistulous segment; however, the artery forming the fistulous connection can be dilated and/or aneurysmal, and maybe mistaken for pericardial cyst, other epithelium-lined cystic structure, ventricular aneurysm, or even sinus of valsalva aneurysm. 
We report a case of a 56-year-old female patient with a giant right coronary artery aneurysm with a fistulous communication to right atrium who presented to us with exertional dyspnea and angina.
| Case report|| |
A 56-year-old female patient presented to us with a history of exertional dyspnea and angina for the past 6 months. She was a nonsmoker and was on antihypertensive medication for the past 5 years.
On physical examination, her pulse was 84 bpm and blood pressure was 150/86 mmHg. Neck veins were not engorged. On cardiac examination, first and second heart sounds were normal; there were no third or fourth heart sounds. A continuous murmur was heard at the left parasternal area. An initial electrocardiogram showed sinus rhythm with no evidence of any chamber enlargement.
A transthoracic echo showed a hugely dilated right coronary artery arising from the right coronary sinus which was communicating with the giant aneurysm and ultimately draining into right atrium with a fistulous communication [Figure 1] [Figure 2] [Figure 3] [Figure 4]. Biventricular systolic function was normal.
The patient was admitted and underwent a transradial coronary angiogram which showed a hugely dilated right coronary artery communicating with a giant aneurysm [Figure 5], [Figure 6]a and b. Coronary angiography was done to confirm the diagnosis as well as to rule out any other pathology which may influence the management of the patient.
|Figure 1: Trans thoracic echo, parasternal long axis view showing the huge right coronary artery aneurysm inferior to the left ventricular cavity|
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|Figure 2: Trans thoracic echo with color Doppler showing continuous flow from the right coronary artery aneurysm to the right atrium|
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|Figure 3: Trans thoracic echo showing the dilated right coronary artery arising from the right coronary cusp|
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|Figure 4: Trans thoracic echo showing the right coronary artery aneurysm draining into the right atrium|
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|Figure 5: Left anterior oblique caudal view showing the huge aneurismal right coronary artery communicating with the right atrium|
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|Figure 6: (a) Left anterior oblique caudal view showing the huge aneurismal right coronary artery. (b) Left anterior oblique caudal view showing the huge aneurismal right coronary artery communicating with the right atrium|
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The patient was referred for surgical management considering the possibility of rupture of the aneurysm and sudden cardiac death. However, the patient declined surgery and was kept on antihypertensive therapy and regular follow-up. Six months after the initial assessment, patient is doing well on medical management with control of her blood pressure and some improvement of her presenting symptoms.
| Discussion|| |
Coronary artery aneurysm is defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. Giant aneurysms, defined as those aneurysms >2 cm in diameter, are rare. , Giant coronary artery aneurysms have been identified throughout the coronary arterial circulation, with the right coronary artery being more commonly affected than the left. ,
The precise mechanism leading to the development of ectasia in the coronary circulation is unknown. Genetic predisposition, risk factors for coronary arterial disease, direct vessel injury, and abnormal vessel wall metabolism are thought to play a part. ,, Some authors suggest that giant aneurysms are more likely to be congenital rather than due to atherosclerosis, unlike their smaller counterparts.  In adults, coronary artery aneurysm is mostly atherosclerotic in origin. Other rare causes include Kawasaki disease, autoimmune disease, trauma, infection, dissection, congenital malformation, and angioplasty. ,
Most of the patients with coronary artery aneurysm are asymptomatic. Those who do present with symptoms may present with angina pectoris, myocardial infarction, and sudden death. Complications such as thrombus formation, embolization, fistula formation, rupture, hemo-pericardium, tamponade, compression of surrounding structure, and congestive heart failure are also seen occasionally. ,,,,,, The presence of a continuous murmur is occasionally noted, and large or calcified aneurysms may be visualized on chest radiography or echocardiogram, but coronary angiography is required for definitive diagnosis and characterization of the aneurysm. ,
Due to the paucity of cases, there is no optimal management strategy for patients with giant coronary artery aneurysms. Different management strategies such as medical management with antiplatelet agents and anticoagulation, stent implantation, and surgical excision have been tried depending on the symptoms, other associated lesions or etiology. ,
| Conclusion|| |
Giant coronary artery aneurysm is a rare anomaly, and clinical presentation may vary from vague chest discomfort to sudden cardiac death. Only a few cases have been identified and there is lack of uniform guideline for management. Hence, each case needs to be treated based on individual experience and expertise. However, very large aneurysms need surgical treatment to reduce the risk of rupture and sudden cardiac death.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]