Delineating anatomy and function with multimodality imaging: a case report of giant right coronary artery aneurysms

Background Giant coronary artery aneurysms (CAAs) are rare and have been reported in patients with connective tissue diseases, arteritides, and atherosclerosis. Given the rarity of the condition, multimodality imaging is essential for comprehensive evaluation of coronary aneurysms and determination of their haemodynamic significance. Case summary A 58-year-old Filipino female was evaluated for dyspnoea on exertion of one month. Chest computed tomography (CT) showed right coronary artery (RCA) aneurysms. Invasive coronary angiogram (ICA) confirmed two giant aneurysms of the RCA. Distal RCA could not be opacified due to contrast stagnation in the proximal aneurysms. Coronary CT angiography (CCTA) depicted an additional giant distal RCA aneurysm not visualized on ICA with intraluminal thrombosis. Contrast-enhanced cardiac magnetic resonance imaging (CMR) revealed delayed time to peak perfusion in the mid to apical inferior walls, on first-pass imaging, without myocardial scarring. Late gadolinium images revealed aneurysmal wall inflammation. Discussion This case highlights the anatomical findings of giant CAA and the application of multimodality imaging for their accurate characterization. While ICA confirmed the presence of the aneurysms, CCTA enabled the assessment of their full extent and depict intraluminal thrombosis. Contrast-enhanced CMR delineated aneurysm wall characteristics, with first-pass images demonstrating reduced inferior wall perfusion at rest, which was likely the cause of patient's exertional symptoms. Management of giant coronary aneurysms involves surgical resection with bypass grafting.