<![CDATA[Background: Coronary artery aneurysms (CAAs) are uncommon, giant forms are extremely rare and the presentation is nonspecific and may mimic other thoracic pathologies. Case Illustration: A 60-year-old male presented with progressive dyspnea, orthopnea, and peripheral edema, five years after open repair of a large fusiform abdominal aortic aneurysm. Echocardiography showed severe left ventricular dysfunction (LVEF 25%) with a mass at the junction of the right atrium and right ventricle, interpreted as a right atrial pseudoaneurysm. CT, however, described an isolated mediastinal mass. Coronary angiography showed a single giant saccular right coronary artery aneurysm (73.1 × 66.9 mm) with trapped contrast and chronic total occlusion of the left main and anterior descending arteries. CT reconstruction indicated the latter occlusion to be a second thrombus-laden coronary aneurysm, to be further evaluated. His previous aortic aneurysm suggested a common predisposition to aneurysms not appreciated during years of disrupted follow-up. He was treated with guideline-directed heart failure, antithrombotic, statin and metabolic therapy. Staged repair was deferred until stabilization. Conclusions: This case demonstrates how a pre-existing diagnosed abdominal aortic aneurysm may mask the recognition of a second coronary aneurysm and perhaps a third in the left coronary system. It emphasizes the importance of considering systemic aneurysmal predisposition in atypical thoracic masses in patients with a history of aortic aneurysm and the role of angiography with cross-sectional imaging in diagnosis.]]>
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