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Rare Case Of Giant Coronary Artery Aneurysm With Diagnostic Dilemma. Case Report
Tamer M. Abdalghafoor, Dina Alwaheidi, Mohamed Salah Abdelghani, Sankar Balasubramanian, Ali Kindawi, Awad Al-Qahtani, Samah Mohamed;
Hamad Medical Corporation, Doha, Qatar
This case report presents the clinical findings and management of a 31-year-old male patient with symptoms suggestive of acute coronary syndrome (ACS). The patient, with no significant medical history, presented with severe chest pain, shortness of breath, nausea, and diaphoresis. Initial evaluation revealed ST-segment elevation on the electrocardiogram (ECG) and elevated troponin levels.
To exclude aortic pathology, a CT aortic angiogram was performed, which incidentally revealed a large rounded structure with soft tissue attenuation and scattered wall calcific flecks, measuring (5.4 x 6.2 x 6.6 cm). This structure was indenting the posterolateral wall of the left atrium (LA) (Figure 1). Subsequent imaging, including transthoracic echocardiography, confirmed the presence of a large mass posterior to the base of the left atrium and left ventricle, measuring (5.5 x 5.6 cm) (Figure 2). This mass was compressing the left atrium and the latro-basal segment of the left ventricle.
Further imaging modalities, including CT coronary angiogram (Figure 3) and cardiac MRI (Figure 4), confirmed the diagnosis of a large distal left circumflex artery (LCX) aneurysm with internal slow turbulent flow, an inferior intramural thrombus, and a recent large myocardial infarction in the LCX territory. Conventional coronary angiogram revealed that the distal circumflex artery was supplying the mass. CT Head did not show any intracranial aneurysms.
The patient underwent excisional removal of the mass, which was found to be intimately associated with the LCX artery, measuring (8 x 6 cm) (Figure 5). The mass was successfully excised using sharp dissection, cautery, scissor, and blunt dissection, and the feeding LCX artery was ligated. Intraoperative transesophageal echocardiogram (TEE) showed trivial to mild mitral regurgitation.
Postoperatively, the patient had a smooth recovery and was extubated on day zero. They were discharged on day 6, on a regimen of aspirin, clopidogrel, and lisinopril. Histopathological examination of the excised mass revealed hyalinized fibroconnective tissue with lipid deposits, foam cells, cholesterol clefts, calcification, and focal inflammatory reaction, consistent with a coronary artery aneurysm. Follow-up visits indicated no symptoms, and the patient had a smooth postoperative recovery.
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