Huge Coronary Aneurysm in a Morbidly Obese Man with Exertional Dyspnea and Chest Pain

Background

Coronary artery aneurysm is a relatively uncommon disease with an estimated incidence of between 1.5% and 5%. There are several causes for this disease, including atherosclerosis, Kawasaki disease, and trauma. Atherosclerosis is the most common cause, accounting for 50% of cases [1]. CAA is called giant when its diameter is more than 4 times the adjacent part or more than 8 mm [2]. Giant coronary artery aneurysm (GCAA) is less common than CAA, with an incidence of 0.02% in the general population [3]. The causes of giant coronary aneurysms are similar to those other coronary aneurysms, and atherosclerosis is the leading cause [4]. A GCAA can also occur following angioplasty [5].

Symptoms of GCAA include chest pain, shortness of breath, and palpitations. However, sometimes patients are asymptomatic [6]. Complications of GCCA include myocardial infarction, thrombosis, and sudden death, so early treatment of this disease is important to prevent mortality [7].

Different surgical procedures can be used, such as aneurysm resection or coronary artery reconstruction. Using the optimal surgical method according to the type of anomaly can play an important role in saving the patient’s life [3]. Percutaneous procedures can be used for GCAA surgery in high-risk patients. Occluding with a detachable balloon or detachable coil is one of these procedures [8]. Excluding GCAA from the native coronary artery can be done by percutaneous stenting of the coronary artery [9,10]. Percutaneous interventions can have complications such as thrombosis, dissection, and no re-flow [11].

Due to the rarity of GCAA, there is no standard surgical approach for this disease, and few cases of GCAA have been reported in the literature [1,12–15]. In this case report, we present an interesting patient with GCAA and our successful treatment.

Case Report

A 64-year-old man was referred to our cardiovascular clinic with exertional dyspnea and chest pain. He had hypertension, opium addiction, and benign prostate hypertrophy. His weight was about 151 kg, and his body mass index was about 46. Coronary angiography was performed. A giant aneurysm was seen at the origin of the left anterior descending (LAD) artery (Figure 1). The patient underwent cardiac surgery. In surgery, we found a clot-filled coronary aneurysm at the origin of the LAD. The aneurysm was behind the pulmonary artery and compressing it. The diameter of the aneurysm was about 42 mm (Figure 2). The aneurysm had many orifices opening to the left main coronary artery, left circumflex artery, LAD, the diagonal branch of the LAD, and the septal branch of the LAD. We decided to keep at least the border so that the orifices were not compromised. We kept the floor of the aneurysm and the orifices and excised other parts of the aneurysm. After aneurysmectomy, a coronary artery bypass graft (CABG) was done using the radial artery to the LAD. Flowmetry showed good flow in the LAD. The patient tolerated the procedure and discharged from the hospital.

Discussion

GCAA is a rare disease that is mainly caused by coronary atherosclerosis [16]. GCAA may be incidentally found in the coronary angiography because the patient can be asymptomatic. In symptomatic cases, the patients can develop chest pain, dyspnea, and palpitations. The right coronary artery appears to be the most involved [1].

GCCA can be fatal. Imai et al reported a 5-year-old boy with a LAD giant aneurysm, who developed cardiac arrest and died [17]. Arboine et al reported a 49-year-old man with GCAA did not tolerate surgery and died [15]. Fatalities may be due to acute myocardial infarction and ventricular tachycardia. Patients may experience sudden death [18]. Crawley et al reported a 56-year-old man who developed with GCCA measuring 70×40 mm. The patient refused cardiothoracic surgery and died 1 month later [19].

Various percutaneous methods have been used for GCAA. These methods include coronary artery stenting and coiling [8–10]. The use of these methods can have short-term and long-term complications for patients [11].

However, there are few cases reports in the literature of patients who survived GCAA. Keyser et al reported a 43-year-old man with a right CAA measuring about 10.6×9.2 cm and 2 small aneurysms. They successfully resected the aneurysm and CABG was performed. He successfully recovered and was discharged [20]. Due to the morbid obesity of the present patient, we had to use a special orthopedic bed for the operation. The surgery was successful and the patient recovered well from the operation.

Coronary artery ectasia is more prevalent in patients with opium addiction [21]. There is little information on the relationship between opium consumption and coronary artery aneurysm [21].

Conclusions

Giant coronary artery aneurysms are rare. Patients with GCAA may experience sudden death due to myocardial infarction and other cardiovascular complications due to ischemia. There is no standard surgical approach for GCAA due to its rarity. Further studies are needed to elucidate standardized surgical management of patients with GCAA.