LAUSR

A 65-years-old male was admitted for effort angina. His past medical history was mainly significant for a coronary artery bypass grafting procedure performed 15 years ago consisting of a left internal mammary artery to left anterior descending artery, a saphenous vein graft (SVG) to an obtuse marginalis and an SVG to posterior descending artery. Four years later, a coronary angiogram revealed an ectatic coronary tree with an occlusion of left internal mammary artery and SVG to posterior descending artery, no significant right coronary artery (RCA) lesion, and patent SVG to obtuse marginalis. Left main (LM) to left anterior descending artery was then stented (unfortunately, no angiogram available). Due to effort angina despite optimal medical treatment, coronary angiogram was performed and disclosed a patent LM stent and an ectatic RCA with a giant aneurysm originated apparently from its mid-segment downstream the two acute marginal branches (Fig. 1a, Supplementary Video 1, Supplemental digital content 1, http://links.lww.com/MCA/ A308). The multislice computed tomography (MSCT) confirmed an origin from the main RCA vessel (white arrow, Fig. 1b) and revealed a giant ‘ping-pong ball’ sized saccular coronary true aneurysm (41×43 mm), in the right atrioventricular groove (Fig. 1b), circulating (star), with a thick layer of mural thrombus which wall was calcified, with no signs of rupture. Despite of low-risk scores (logistic Euroscore 3.49 %, Euroscore II 2.07 %, and a The Society of Thoracic Surgeons score of 1.34 %), the Heart Team decided to treat the aneurysm percutaneously to avoid a second sternotomy. No side branches were originated within the subtended aneurysm, and the neck was clearly visible (white arrow). An 6F Amplatz left 1 (Mallinckrodt) guiding catheter was used to engaged the right coronary artery and a Runthrought guidewire (Terumo, Japan) was placed distally. A 4×20 mm followed by a 4.5×26 mm PK-Papyrus polyurethane-covered stents (Biotronik, Berlin, Germany)