PMC10244565_01
Multimodal imaging. (A) Anteroposterior chest x-ray. (B) Bronchoscopy view at the level of the left lobar bronchus. (C) Coronal view of thoracic MRI. (D) Coronary CT angiography demonstrating LAD with a large aneurysm wrapped in the hematoma (asterisk). (E) Preoperative coronary CT angiography: 3D reconstruction view. (F) Coronary angiography. LAD, left anterior descending artery.
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Chest x-ray (Figure 1A) showed an enlarged left cardiac silhouette with a conspicuous bulge encroaching on the left upper-middle lung field. In addition, bronchoscopy (Figure 1B) detected fresh blood in the left upper lobe bronchus, however, the definitive bleeding source was not identified. MRI with a T1W1 sequence (Figure 1C) demonstrated that the heterogeneous mass was essentially caused by active bleeding, and the possible diagnosis of a mediastinal tumor was excluded. Meanwhile, coronary CT angiography (Figures 1D,E) revealed a giant suspicious left coronary artery aneurysm (37 mm x 23 mm) wrapped in a large mediastinal mass (103 mm x 75 mm), which extended to the left chest wall and infiltrated the lung lobe. Furthermore, coronary angiography (Figure 1F; Supplementary Video S1) confirmed a saccular CAA originating from the middle portion of the left anterior descending artery.
Intraoperative findings and postoperative images. (A) Ruptured CAA. (B) Coronary artery bypass surgery. (C) Postoperative coronary CT angiography: 3D reconstruction view. SVG, saphenous vein graft; AO, aorta; PA, pulmonary artery; RCA, right coronary artery; LCX, left circumflex artery; LAD, left anterior descending artery.
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After the removal of the limited thrombi eroding the left pleura densely and adhering to the left upper lung, a large pseudoaneurysm arising from a ruptured left CAA was identified (Figure 2A; Supplementary Video S2). The aneurysmal sac was resected, and a saphenous vein graft was used to bypass the distal left anterior descending artery (Figure 2B). The patient recovered uneventfully with cessation of hemoptysis, and predischarge CTA 9 days after surgery showed the disappearance of the left CAA (Figure 2C).