Multiple Giant Calcified Aneurysms

Multiple Giant Calcified Aneurysms of Three Coronary Arteries

A 39-year-old young man was referred to the division of cardiology due to multiple giant aneurysms involving 3 major epicardial coronary arteries. He had no chest pain and dyspnea, no specific past medical or familial histories, and no risk factors for coronary artery disease. He visited the department of occupational and environmental medicine of our medical center for medical check-up. Cardiac computed tomography angiography (CTA) revealed totally occluded thrombosed giant calcified aneurysm in the proximal left anterior descending artery (LAD) (Fig. 1A, blue arrow), a thrombosed giant calcified aneurysm in the proximal left circumflex artery (LCX) (Fig. 1B, red short arrow), and a giant calcified aneurysm with mixed plaque in the proximal right coronary artery (RCA) (Fig. 1C, yellow arrowhead) and a giant aneurysm in the middle RCA (Fig. 1C, purple arrowhead). At the time of referral and coronary angiography, the patient's laboratory data showed no specific abnormalities or any evidences of metabolic syndrome. Fluoroscopy showed egg-shaped calcification in each three coronary artery aneurysm (Fig. 1D, each arrow in Fig. 1D, E, F is corresponding with same colored and shaped arrow in CTA), and coronary angiogram revealed a chronic total occlusion with giant calcified aneurysm in the proximal LAD, a giant aneurysm in the proximal LCX with good distal flow (Fig. 1E), and a giant calcified aneurysm in the proximal RCA, and an aneurysmal dilatation in the middle RCA (Fig. 1F). We decided to transfer the patient to the department of cardiovascular surgery for coronary arterial bypass graft.

About 40-87% of coronary aneurysm involves the RCA, and three-vessel or left main involvement is rare finding. And cases including a giant aneurysm are even rarer. In our case, the patient was relatively young, without any features concerning common etiologies of coronary aneurysms or symptoms suggesting coronary artery disease, and had giant calcified coronary aneurysms involving 3 vessels.

Fig. 1. Computed tomography angiography (CTA) imaging and coronary angiography of the 3 coronary arteries. (A) The left anterior descending artery (LAD) showing a totally thrombosed aneurysmal dilatation in the proximal LAD (Blue arrow). (B) Left circumflex artery (LCX) with a thrombosed giant aneurysm in the proximal LCX (red short arrow). (C) Right coronary artery (RCA) with 2 aneurysms in the proximal (yellow arrowhead) and middle RCA (purple arrowhead). (D) Fluoroscopy showing egg-shaped calcification in each three coronary artery aneurysm (each arrow in D, E, F is corresponding with same colored and shaped arrow in CTA); (E) Coronary angiography revealing a chronic total occlusion with giant calcified aneurysm in the proximal LAD, a giant aneurysm in the proximal LCX with good distal flow. (F) Giant calcified aneurysm in the proximal RCA, and an aneurysmal dilatation in the middle RCA.

References

1. Cohen P, O'Gara PT. Coronary Artery Aneurysms: A Review of the Natural History, Pathophysiology, and Management. Cardiol Rev 2008;16:301-304.