Coronary artery aneurysms are defined as dilatations exceeding 1.5 times the normal vessel diameter. They are often incidental findings but can present with angina, thrombosis, or rupture. While small, asymptomatic aneurysms can be managed conservatively, giant aneurysms frequently require intervention [1]. Historically, surgical ligation or resection was the standard treatment, but endovascular techniques, including covered stents, coils, and vascular plugs, have become viable minimally invasive alternatives [2, 3]. The Amplatzer Vascular Plug (AVP) is a self-expanding nitinol mesh designed for precise occlusion of abnormal vascular structures. It has proven effective for coronary fistulas and pseudoaneurysms, with increasing off-label use in complex coronary pathologies [3, 4].

A 62-year-old male patient with a past medical history of smoking and hypertension presented with malaise to the emergency department and was diagnosed with inferior ST elevation myocardial infarction (STEMI). Diagnostic coronary angiography demonstrated a large aneurysmal dilatation of the mid-distal right coronary artery (RCA) segment with occlusion of the distal right coronary artery runoff. Acute percutaneous revascularization was unsuccessful due to the anatomic challenges posed by the aneurysm, in both antegrade and retrograde approaches. Given the high surgical risk, an acute coronary artery bypass grafting (CABG) operation was deferred by the heart team, and the patient was managed conservatively. The patient remained on dual antiplatelet therapy for acute coronary syndrome without anticoagulation, anticipating spontaneous thrombosis of the aneurysm. The patient’s cardiac rehabilitation was uneventful. Cardiac computed tomography angiography (CTA) at 1-month follow-up showed a persistent flow in the giant right coronary artery aneurysm. Of technical note for CTA images is the incomplete, hazy filling, which can be misinterpreted as aneurysm closure or thrombosis (Figure 1 A). In case of doubt, comparison with native images and/or delayed phase (180 s) CTA images can help to differentiate between partial filling and complete thrombosis [3]. A repeat Heart Team discussion, considering the already occluded distal RCA runoff, recommended a percutaneous closure to avoid possible complications, such as aneurysm rupture. Conventional use of covered stents was not feasible due to the aneurysm’s large size and absence of a distal runoff/landing zone. However, the patient was complaint-free, and the distal RCA runoff was already totally occluded (no further revascularization planned), allowing the operators to use an unconventional approach: a proximal vascular plug to completely seal and thrombose the aneurysm.

Figure 1

A – Cardiac CTA curved multiplanar reconstruction images showing a giant right coronary artery aneurysm with slow contrast filling (white arrow) and a wall thrombus (black arrow). B – Percutaneous closure of the giant RCA aneurysm. Deep intubation with an AL-1 7F guide and engagement with a Sion Blue ES wire. C – Successful deployment of an Amplatzer Vascular Plug II device 10 × 7 mm (white arrow) in the proximal RCA, with minimal contrast flow persisting at the end of the intervention (black arrow). D – Contrast-enhanced cardiac CTA images 3 months after vascular plug implantation (black arrow) showing successful isolation and complete thrombosis of the giant RCA aneurysm (white arrow)

CTA – computed tomography angiography, ES – extra support, RCA – right coronary artery, AL – Amplatz left.

The access site for the procedure was the right femoral artery. As detailed before, to avoid possible ischemia, collateral flow of the distal RCA from the left anterior descending artery was confirmed. The RCA was engaged using a 7 French AL-1 guiding catheter and a Sion Blue ES wire. Device selection (Amplatzer Vascular Plug II, 10 × 7 mm) was based on intravascular ultrasound (IVUS) imaging and prior CTA images. The plug was advanced and deployed at the ostium of the RCA, with minimal residual flow detected through the device at the end of the intervention. Complete occlusion was confirmed by cardiac CTA at the 3-month follow-up.

To conclude, we report successful percutaneous closure of a giant right coronary aneurysm using the Amplatzer Vascular Plug, with CTA follow-up demonstrating complete thrombosis of the aneurysm at 3 months.