Surgical Management of a Ruptured Giant Right Coronary Artery Aneurysm With Fistulization

Coronary artery aneurysms (CAAs) are an uncommon condition with severe long-term consequences. We describe the surgical treatment of a right CAA that manifested as a compressive mass adjacent to the right atrium. A 60-year-old female patient presented with mid-sternal chest discomfort and a CT scan showing a 6.3cm x 5.5cm x 7cm mass along the anterior chest wall compressing the right atrium. Angiography revealed 95% proximal right coronary artery stenosis with contrast filling a giant CAA but no antegrade filling beyond the aneurysmal sac. While hospitalized, the patient experienced acute hypotension, and an urgent CT scan demonstrated interval bleeding into the pericardial sac with significant external compression of the right ventricular outflow. The patient was urgently taken to the operating room, where the right CAA was ligated at the neck and oversewn at the ostium. The patient developed a hemothorax on postoperative day 1 without a clear source of bleeding, but the remaining postoperative course was uneventful. Opportunities for surgery in patients with ruptured CAAs are rare due to the high pre-hospital mortality rate. Complex percutaneous coronary intervention is the preferred initial approach for asymptomatic CAAs, as was performed in this patient eight years prior. However, in the setting of acute tamponade, urgent operative intervention is the only viable management option. Aneurysmal rupture is an uncommon complication of CAAs that frequently leads to sudden death. This case demonstrates the successful management of an acutely ruptured CAA with urgent aneurysm ligation.