A case of right coronary artery aneurysm complicated by endovascular thrombosis

Abstract Coronary artery aneurysm is a rare disorder with prevalence in male population. The most commonly involved vessel is the right coronary artery followed by the anterior descending artery. The most frequent etiologies are coronary atherosclerosis and Kawasaki disease. The treatment of coronary aneurysms with significant stenosis is often surgical, with implantation of covered stents in case of saccular aneurysms. In coronary artery aneurysms without significant stenosis, medical therapy is often the most suitable choice. Case report We present a case of a 68–year–old man with history of hypertension and dyslipidemia, who arrived to our ED with inferior STEMI. Left coronary angiography showed a 75% stenosis of the distal anterior descending artery and subocclusion of the first left marginal artery. Right coronary angiography revealed a severely ectatic vessel (7–8 mm diameter) with intraluminal thrombosis and markedly slowed flow (TIMI 1). Considering the regression of symptoms and ECG alterations, intracoronary bolus of Tirofiban was performed followed by i.v. infusion of 24 hours in association with DAPT. Blood tests did not detect any relevant alterations of coagulation profile but only an heterozygous mutation for MTHFR with slightly altered homocysteine values. Six days later, a second coronary angiography was performed which confirmed the persistence of thrombotic formation into the right coronary artery that was treated with rheolytic thromboaspiration and TIMI 2 final flow. In consideration of the angiographic findings, it was decided not to implant coronary stents. After multidisciplinary team discussion it was decided to associate DAPT with oral anticoagulant therapy (Warfarin 5 mg, INR 2–3) The patient was discharged with indication to continue the triple antithrombotic therapy for 6 months followed by double antithrombotic therapy with ASA and Warfarin. Conclusions Coronary aneurysms in the context of ACS are rare findings, often caused by endovascular thrombosis. Thrombolytic therapy, rheolytic thromboaspiration and anticoagulation therapy are valid tools for the successful treatment of such cases.