Case Report:
A 47-year-old Hypertensive, non-insulin dependent diabetic gentleman presented to the emergency department with recurrent attacks of chest pain suggesting unstable angina. His diagnostic workup included blood tests, Echocardiography, left heart catheterization which demonstrated a huge dilatation of the right coronary artery with proximal and distal stenosis (Figure IA), and multi-vessel coronary artery disease involving the left coronary system (Figure IB) and Contrast-enhanced chest CT (Figure IC). In the present case, our patient had 3 vessel coronary artery disease with strong symptoms, and also having right sided dominant circulation with a posterior descending artery measuring 1.5 mm in diameter, and no major branch such as marginal or sinoatrial arteries could be demonstrated to take off from the giant right coronary aneurysm by examining various views of the right coronary angiogram. In the view of the patient presentation and the presence of multi-vessel coronary artery disease and the presence of the giant right coronary artery aneurysm, decision was taken to offer our patient the option of coronary artery bypass grafting with ligation of the right coronary artery aneurysm.
Surgery was performed via median sternotomy; the left internal thoracic artery (LITA) and left great saphenous vein (GSV) were harvested as conduits. Routine Cardiopulmonary bypass and cardioplegia was used. The right coronary artery aneurysm was isolated proximally and distally. It was then ligated with Proline 4/0 threads (Figure I D), Extreme caution was taken not to excessively mobilize the giant aneurysm in order to prevent distal embolization of calcium or debris into the distal right coronary artery territory. Luckily, there were no branches in the RCA at the location of the aneurysm, and distal to the ligation, the posterior descending branch of the RCA was grafted with saphenous vein. Remaining part of the procedure was completed and patient weaned uneventfully off cardiopulmonary bypass with good ventricular function and in normal sinus rhythm. Dual antiplatelet therapy was initiated in the second day postoperatively.