Giant right coronary artery aneurysm with recurrent thrombosis and cardiac arrest in a young adult: a case report

Abstract Background Coronary artery aneurysms are uncommon and may present with acute coronary syndromes due to thrombotic complications. Giant coronary artery aneurysms, particularly involving the right coronary artery, pose significant diagnostic and therapeutic challenges, especially in young patients without traditional cardiovascular risk factors. Case presentation We report the case of a 37-year-old previously healthy male who presented with sudden-onset severe chest pain and electrocardiographic findings consistent with inferior ST-segment elevation myocardial infarction. Emergency coronary angiography revealed a giant right coronary artery aneurysm measuring 16.9 mm in maximal diameter and 33.5 mm in length, with distal thrombotic occlusion. Thrombus aspiration restored normal coronary flow, and the patient was initially stable on intensive antithrombotic therapy. Twenty-four hours later, he developed recurrent chest pain followed by cardiac arrest requiring prolonged cardiopulmonary resuscitation. Repeat angiography demonstrated re-occlusion of the right coronary artery due to extensive thrombosis. Repeat thrombus aspiration was performed, and intra-aortic balloon pump support was instituted. The post–cardiac arrest course was complicated by transient multiorgan dysfunction, which gradually resolved with intensive supportive care. Extensive etiologic workup was unremarkable. Following multidisciplinary Heart Team discussion, surgical revascularization was proposed but declined by the patient. He was managed conservatively with anticoagulation and single antiplatelet therapy. At three-month follow-up, coronary angiography demonstrated chronic total occlusion of the right coronary artery with complete thrombosis of the aneurysmal segment. Conclusions Giant coronary artery aneurysms may remain clinically silent until catastrophic thrombotic events occur. This case highlights the limitations of medical therapy alone in preventing recurrent thrombosis and underscores the importance of individualized management, close follow-up, and multidisciplinary decision-making in this high-risk population.