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Acute Myocardial Infarction Associated With Multiple Giant Coronary Artery Aneurysms: A Management Dilemma
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A 77-year-old man presented with an acute inferior ST-segment elevation myocardial infarction. Peak troponin was 26 times higher than normal, and echocardiography showed impaired left ventricular (LV) systolic function; the ejection fraction (EF) was 40%. An emergent coronary angiography demonstrated a large right coronary artery (RCA) proximal aneurysm with an acute occlusion at the neck (Figure).
The occlusion was crossed with a Fielder XTA wire (Asahi) with the help of Supercross microcatheter (Teleflex). Following balloon pre-dilation at the neck, 2 further large aneurysms were visualized. The left anterior descending (LAD) artery demonstrated mildly diffuse disease throughout the vessel, and the left circumflex artery (LCX) had a mid-vessel chronic total occlusion with another proximal aneurysmal segment.
A discussion was prompted with the Heart team, and considering the complexities of the patient’s anatomy, as well as the lack of distal targets, it was decided that it would be better suited for the patient to be treated medically. Cardiac computed tomography was also carried out and showed the same RCA and LCX aneurysms. Autoimmune, inflammation, and infection screens were negative, and the likely aetiology was felt to be atherosclerosis. He was discharged on long-term aspirin and rivaroxaban with a plan of routine follow-up.
Figure. (A) Angiogram of the RCA with a large proximal aneurysm (triangle). (B) Following balloon angioplasty to aneurysm neck, 2 further aneurysms are visualized (triangle). (C) Pre-stenotic aneurysm of the LCX (triangle). (D) Echocardiogram showing RCA aneurysm and small localized pericardial effusion (asterisk). (E) CT coronal section demonstrating RCA aneurysm (asterisk). (F) CT transverse view demonstrating RCA (asterisk) and LCX (triangle) aneurysms. CT = computed tomography; LCX = left circumflex artery; RCA = right coronary artery.
Affiliations and Disclosures
From the 1Freeman Hospital, Newcastle upon Tyne, United Kingdom; 2South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Address for correspondence: Md Azizul Hasan Khandaker, FCPS, MRCP, MD, Cardiology Department, Freeman Hospital, Freeman Road High Heaton, Newcastle upon Tyne, NE7 7DN, UK. Email: drazizul07@yahoo.com
