Clin. Cardiol.

20, 79-81 ( I 997)

Paracardiac Masses Caused by a Right Coronary Artery Aneurysm and

a Saphenous Vein Graft Aneurysm
PRASAD
CHALASANI,
M.D., DONNA
KONLIAN,M.D., STEPHEN
CLEMENTS,
M.D.

Division of Cardiology, Emory University School of Medicine,Atlanta, Georgia,USA

Summary: Two unusual cases of large aneurysms, one located in the native right coronary artery and the other in a saphenous vein graft, are reported. Their size and mode of presentation as asymptomatic paracardiac masses on chest x-ray films
make them unique. It is proposed that these entities be considered as part of the differentialdiagnosis of paracardiac masses.

Key words: coronary artery aneurysms, abnormal chest xrays, differentialdiagnosis, management

Introduction
Aneurysms of the coronary arteries are quite unusual and
have an estimatedincidence of about 1.5% at necropsy or coronary arteriography. Coronary artery aneurysms are more common in individualsless than 20 years of age, especially ifangina pectoris or an acute myocardial infarction have occurred.2
Previously reported cases of saphenous vein graft aneurysms
or native coronary artery aneurysms have differed distinctively
in size and presentation from the cases to be discussed.-5

Case Reports
Case No. 1
A 77-year-old, previously healthy woman was admitted
with pneumonia to a local hospital. She was found to have a

Address for reprints:

Stephen elements, M.D.
The Emory Clinic
1365 Clifton Road, N.E.
Atlanta, GA 30322, USA
Received: April 20, 1995
Accepted with revision: October 9, 1995

mass adjacent to the right heart border on the routine chest xray film (Fig. 1). Further evaluation of this mass with computed tomography (CT) revealed a large fluid-filled sac within the
pericardium (Fig. 2). There were no symptoms.
Magnetic resonance imaging of the chest identified the
fluid filled sac to be most likely a large aneurysm ofthe light
coronary artery (RCA), 1 cm distal to its ostium.
Cardiac catheterization revealed a normal left coronary
artery. The catheter dropped down into a large area as the right
coronary ostium was cannulated. Contrast material was not injected. A contrast aortogram revealed shunting of contrast
from the right coronary cusp into the aneurysm.
At cardiac surgery, a 12 X 14 cm aneurysm of the right
coronary artery waq identified,displacing the right atrium posteriorly. The coronary sinuses were normal. The aneurysm
was resected and the right coronary artery was bypassed. Pathologic examination revealed a large coronary aneurysm filled
with thrombus.

Case No. 2
A 61-year-old hypertensive, hyperlipidemic female patient, with a history of coronary artery bypass surgery 8 years
previously, was admitted for hip surgery to a local hospital. A
preoperative chest x-ray film (Fig. 3 ) revealed an abnormal
mass distorting the left cardiac border. A CT-guided aspiration of the mass revealed blood. Serial chest x-ray films had
revealed a gradual increase in size of the mass. The chest was
explored and an aneurysm of the saphenous vein graft was
identified. Accelerated hypertension during the surgery precluded any further intervention. Later, the patient recovered
and was transferred to Emory University Hospital for further
treatment.
Cardiac catheterization revealed a very large aneurysm of
the saphenous vein graft to the left anterior descending coronary artery (Fig. 4). The patient underwent cardiac surgery,
which showed a 6.2 X 3.4 cm aneurysm of the saphenous
vein graft. The aneurysm was resected and the left internal
mammary artery was implanted to the left anterior descending artery. Pathologic examination of the excised aneurysm
showed chronic inflammatory changes and calcification of
the vascular intima with organized thrombus. The patient recovered fully.

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Clin. Cardiol. Vol. 20, January 1997

FIG.1 Chest x-ray showing abnormal right cardiac silhouette.

Discussion
The most widely accepted definition of a coronary artery
aneurysm is dilatation of more than 1.5 times the diameter of
the adjacent normal segment of the largest coronary artery.3
In a series of 8,422 patients, only 20 patients were identified
with discrete aneurysms, most of which were < 2 cm in diameter. The two aforementioned case reports are unique because of the exceptional size of the right coronary artery and
saphenous vein graft aneurysms-12 X 14 cm and 6.2 X 3.4
cm, respectively.
The major causes of aneurysms of the coronary arteries include atherosclerosis, trauma, angioplasty, artherectomy, and

FIG.3 Chest x-ray showing abnormal left cardiac border simulating left parahilarmass.

FIG.2 Computed tomography scan of cheat showing 7.2 X 8 cni

fluid-filled sac inside the pericardium.

mycotic, Kawasaki, and congenital diseases. The aneurysm of

the right coronary artery was believed to be congenital, because microscopy revealed a normal arterial wall.
The saphenous vein aneurysm had degenerative changes
with calcification and chronic inflammation.
Most coronary artery aneurysms reported in the literature
have been diagnosed by coronary arteriography performed for
other reasons. Rarely do coronary aneurysms present with
myocardial ischemia and infarctionsfrom thrombosis and ernbolic events involvingthe aneurysm,4.6with rupture into vari-

FIG.4 Saphenous vein arteriograrn showing a large aneurysm and

a tight lesion distal to the aneurysm.

P. Chalasani et al.: Paracardiac masses

ous cardiac chambers,s or with abnomial paracardiac masses
on echocxdiograms and noninvasive imaging of the chest!.
In both of our patients, the incidental finding of a paracardiac
mediastinal mass was striking and required further workup. In
Case No. 2, diagnostic aspiration was attempted under CT
guidance because a saphenous vein graft aneurysm was not
entertained in the differential diagnosis secondary to its rarity.
Surgery is the treatment of choice in cases in which the size
of the aneuiysm poses significant risk, such as rupture, or if
symptoms are p r e ~ e n tIn
. ~our cases, surgery was indicated because of the size of the aneurysms and the potential for rupture.

Conclusion
Two unusual cases of aneurysms of the coronary circulation
are presented in order to broaden the differential diagnosis of
the individuals with paracardiac masses.

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