Giant Thrombosed Coronary Aneurysm Causing Recurrent Ischemic Events

Background: Giant coronary artery aneurysms are rare and may cause thrombosis, distal embolization, and myocardial infarction. Owing to their low prevalence, optimal management remains uncertain. Case summary: A 56-year-old man presented with a non-ST-elevation myocardial infarction. Coronary angiography showed diffuse coronary ectasia and aneurysms, chronic right coronary artery occlusion, and no significant obstructive stenosis. Percutaneous revascularization failed because of the complex aneurysmal anatomy. Three years later, recurrent angina prompted multimodality imaging. Cardiac magnetic resonance revealed preserved left ventricular ejection fraction, inferior wall akinesia, transmural late gadolinium enhancement consistent with prior infarction, and new lateral wall motion abnormalities. Cine and tissue-characterization sequences suggested a giant partially thrombosed left circumflex aneurysm, confirmed by coronary computed tomography angiography, which demonstrated an hourglass-shaped aneurysm with minimal residual lumen. The patient underwent successful thrombectomy, capitonnage, and triple coronary artery bypass grafting. Discussion: Multimodality imaging is essential for diagnosis and surgical planning, whereas treatment should be individualized according to aneurysm morphology and clinical presentation. Take-home messages: Thrombosed coronary artery aneurysms may be underestimated by coronary angiography because of limited opacification of the aneurysmal sac. Multimodality imaging, integrating coronary computed tomography angiography and cardiac magnetic resonance with angiography, provides complementary information on aneurysm anatomy, thrombus burden, vessel wall characteristics, and myocardial involvement, thereby supporting diagnosis and individualized management.