Coronary artery aneurysms are rare, with an incidence of 0.15% to 4.9% on angiography. Giant coronary artery aneurysms are even rarer, with an incidence of 0.02%. In most cases, only single coronary artery aneurysms have been reported. We performed an autopsy on a 61-year-old man with multiple comorbidities, including hypertension, diabetes, congestive heart failure, and myocardial infarction with aortic and bilateral iliac aneurysms. His hospital course was complicated by multiorgan failure, cardiorenal syndrome, and severe coagulopathy. Grossly, the heart showed hypertrophy (990 g) with fibrotic scars in both the anterior and posterior left ventricle. The left anterior descending, left circumflex and right coronary arteries were involved by severe atherosclerosis and showed aneurysmal dilatation ranging in size from 0.5 cm to 2.3 cm. Histologic analysis of the vessel walls revealed atherosclerotic changes and focal hemorrhage with multiple focal healed and more recent myocardial infarct involving the left ventricle and papillary muscles. Coronary artery aneurysm is defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. Giant aneurysms are defined as those greater than 2 cm in diameter. Matrix metalloproteinases (MMPs) have been implicated in the pathogenesis of aneurysms through increased proteinolysis of extracellular matrix proteins and collagen in the vessel wall during atherosclerotic vascular remodeling. In our patient, the simultaneous presence of aortic, bilateral iliac aneurysms and coronary artery disease, along with the histologic findings, indicate atherosclerosis as the cause of the giant coronary artery aneurysms and suggest a mutation in MMP genes. To the best of our knowledge, only a single case report of giant aneurysms involving all 3 major coronary arteries has been reported. Published guidelines have been based on anecdotal experience rather than controlled trials. This is in part related to the rare nature of the disease, making it difficult to conduct such a trial.
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