2024 Scientific Sessions

Title:
An interesting case of an RCA anomaly

Introduction:
Coronary artery aneurysms may vary in terms of their presentation and there are no large scale outcomes on the different treatment modalities. Treatment modalities include medical management, surgical excision, CABG and PCI. We present a case of a patient that was deemed to have prohibitive surgical risk who ultimately underwent PCI with covered stents for coronary artery aneurysm.

Clinical Case:
82 year old male with a PMH of major depressive disorder, Type II DM, CKD stage III, BPH, paroxysmal AF, gall stone pancreatitis (s/p lap cholecystectomy 7 years prior) who initially presented for hernia repair (diaphragmatic hernia). He underwent robotic assisted laparoscopic diaphragmatic hernia repair and a left thoracostomy tube was left in place due to a collapsed lung. He was noted to have continued bleeding from the chest tube and a CTA of the chest was performed as part of his evaluation. His CTA revealed a cystic structure next to his RA that was concerning for an RCA aneurysm and he was referred to cardiology. A dedicated coronary CTA and an echocardiogram were performed as part of his evaluation. His coronary CTA confirmed the presence of a large RCA aneurysm (unable to perform FFR due to aneurysm) and a possible obstructive LAD lesion (FFR could not be performed due to heavy calcification). Due to poor acoustic windows a TEE was obtained that revealed layered thrombus in the aneurysm along with some compression of the right sided heart structures. A coronary angiogram was performed confirming the presence of the aneurysm and FFR of the LAD was performed, which showed that the lesion was non-significant. CT surgery was consulted during the index hospitalization and the decision was made to follow-up as an outpatient (given his recent surgery). During his follow-up with CT surgery he was deemed to be high risk for surgery due to his advanced age and comorbidities and was advised to consider his percutaneous options. He was referred to our clinic, and after discussing with the patient and his family; the decision was made to pursue PCI with covered stents to exclude his aneurysm. The patient successfully underwent the procedure with excellent angiographic results showing no extravasation of contrast into the aneurysm with RCA injections. He underwent a Coronary CTA 4 weeks post procedure which revealed thrombosis of the aneurysm with no active flow into the aneurysm.

Discussion:
Coronary artery aneurysms may at times be difficult to treat. Large aneurysm may require CT surgery consultation as they may be best served with surgery. For patients at prohibitive surgical risk or who wish to avoid surgery, percutaneous options such as coiling or exclusion with covered stents exists. We show that exclusion of a large RCA aneurysm using can be safely performed in a patient with prohibitive surgical risk using covered stents