Abstract 4370301: Endovascular Management of a Giant Right Coronary Artery Aneurysm With Right Atrial Compression

Description of Case: Giant coronary artery aneurysms (CAAs) are rare and pose diagnostic and therapeutic challenges, particularly when asymptomatic or incidentally discovered. Right atrial (RA) compression due to CAA is extremely uncommon and lacks standardized management guidelines. We report a 59-year-old man with prior inferior ST-elevation myocardial infarction (2009) and known right coronary artery (RCA) ectasia, presenting with dyspnea at rest and new-onset atrial fibrillation. Physical examination revealed hypoxemia, bilateral lower extremity edema, and bibasilar crackles. Transthoracic echocardiography showed mild biventricular dysfunction and biatrial enlargement. Pulmonary computed tomography angiography excluded thromboembolism but incidentally identified a 6.6 × 6.4 cm proximal RCA aneurysm. Coronary computed tomography confirmed RA compression without tamponade or restrictive physiology. Right heart catheterization showed normal pulmonary artery pressures, excluding pulmonary hypertension. The patient remained hemodynamically stable and was initially discharged on optimal medical therapy. Coronary angiography revealed RCA occlusion with retrograde perfusion via left anterior descending artery collaterals. After multidisciplinary Heart Team discussion, conservative management was initially considered. However, due to aneurysm size and risk of complications, an endovascular approach was pursued. Methods: The patient underwent percutaneous intervention under conscious sedation, utilizing dual arterial access (right femoral and left radial). The procedure included selective RCA catheterization, balloon occlusion testing proximal to the aneurysm, and deployment of a vascular plug at the RCA ostium. Discussion: Selective RCA catheterization was achieved, and a 0.014-inch guidewire was advanced into the aneurysmal sac. Balloon occlusion was performed proximal to the aneurysm to test for tolerance, followed by deployment of a vascular plug at the RCA ostium, achieving aneurysm exclusion. The patient remained stable throughout, with no clinical or electrical instability. Post-procedural imaging confirmed cessation of flow into the aneurysmal sac, without new compressive or ischemic complications. This case highlights the importance of individualized, multidisciplinary management in rare giant CAAs. In selected patients with preserved hemodynamics and suitable anatomy, endovascular exclusion with vascular plugs offers a safe and effective alternative to surgery.