Resha Reya Ganthan MD¹, Salar Shahzad MD¹, Asher Gorantla MD³, Gautham Upadhya, MD, FACC², Francesco Rotatori MD, FACC²

 ¹Department of Internal Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA

²Department of Cardiology, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA

³Department of Cardiology, State University of Downstate New York, Brooklyn, NY, USA

Corresponding Author: Resha Reya Ganthan MD, Department of Internal Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA

Citation: Resha Reya Ganthan, Salar Shahzad, Asher Gorantla, Gautham Upadhya, Francesco Rotatori, (2025) Beyond the STEMI; Unmasking A Coronary Artery Aneurysm. World J Case Rep Clin Imag. 2025 June; 4(1)1-10.

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Abstract

Background

Coronary artery aneurysms (CAAs) are relatively rare defects that range significantly in clinical presentation, most often discovered in adults with concomitant coronary artery disease. There remains no general consensus on the optimal management of CAAs. A vast majority of cases reported in literature are managed operatively or with percutaneous stenting. We however demonstrate a case of a CAA discovered upon angiography for a STEMI managed entirely with intracoronary thrombolytics and intravenous heparin, followed by a repeat coronary angiography that confirmed re-opening of the occluded vessel now with distal coronary blood flow.

Case Summary

In this case we present a 46-year-old male with a past medical history of hypertension (HTN), hyperlipidemia (HLD), type 2 diabetes mellitus (T2DM), and obesity who was brought to the emergency department for crushing, substernal chest pain. Electrocardiogram (EKG) demonstrated ST segment elevations in leads V3-V6 and leads II, III, and AVF. Coronary angiography revealed severe ectasia, with an aneurysm of the middle LAD containing a 100% thrombotic occlusion. A repeat angiography 24-hours later demonstrated diffuse coronary ectasia, with a now patent LAD, and the presence of a focal 10 mm aneurysm of the mid left anterior descending (LAD) artery. There was poor distal flow of the LAD with complete occlusion in the apical region. The patient was not a candidate for percutaneous coronary intervention (PCI) due to the large thrombotic burden, and risk of propagation of the clot, thus the decision was made to manage medically. This case highlights a unique presentation of CAA with a superimposed thrombus, causing a complete total occlusion of the mid LAD, resulting in the initial hospital presentation as an ST-segment elevation myocardial infarction (STEMI).

Keywords: Coronary Artery Aneurysm (CAA); Coronary Artery Disease (CAD); Coronary Artery Ectasia (CAE)

Teaching Point(s)

· Coronary artery aneurysms are pathological dilations of a coronary vessel that may present as a nidus for thrombus formation, and may obstruct blood flow resulting in an acute coronary syndrome presentation

·  There exists no cohesive guidelines in the optimal management of coronary artery aneurysms, which may present as a treatment challenge for interventional cardiologists

·  Coronary aneurysms are frequently not amenable to stenting due to risk of clot propagation and stroke, resulting in medical management with intracoronary thrombolytics

Abbreviations:

ACS: Acute coronary syndrome

CAA: Coronary artery aneurysm

CAD: Coronary artery disease

CAE: Coronary artery ectasia

DAPT: Dual antiplatelet therapy

EKG: Electrocardiogram

LCX: Left circumflex artery

MACE: Major adverse cardiovascular event

NSTEMI: Non ST-segment elevation myocardial infarction

PCI: Percutaneous coronary intervention

PDA: Posterior descending artery

RCA: Right Coronary Artery

STEMI: ST-segment elevation myocardial infarction

Transthoracic echocardiogram (TTE)