Background:
In the Kawasaki disease (KD) the giant coronary aneurysms (GCA) may evolve into stenosis, thrombosis, and complex coronary remodeling requiring lifelong surveillance and advanced interventions.
We report the case of a child who had underwent revascularization by PCI on calcified chronic occlusion of the proximal left anterior descending artery (LAD) and the management of complications.
Case presentation:
We report the case of a 15-year-old male with Noonan syndrome and a history of Kawasaki disease complicated by GCA of proximal right coronary artery (RCA) and proximal LAD diagnosed in 2012. A cardiac catheterization performed 3 years later showed subacute occlusion of the RCA aneurysm with heterocoronary recirculation, in absence of symptoms.
Coronary CT angiography performed in April 2025 showed and a large, calcified aneurysm of the proximal LAD with intraluminal thrombotic component. Myocardial perfusion imaging demonstrated preserved ventricular size and no inducible ischemia.
In July 2025, coronary angiography (CA) and OCT revealed severe aneurysmal disease of the proximal LAD with heavy calcification and a significant bifurcation stenosis with the first diagonal. Percutaneous coronary intervention (PCI) was performed with Shockwave Intravascular Lithotripsy (IVL) and drug-eluting stent implantation in the LAD and balloon angioplasty of the diagonal branch.
Three-month follow-up CT showed a patent stent but development of a large peri-stent pseudoaneurysm (up to 14 mm, 30 mm length) with partial intraluminal thrombosis. Subsequent CA and IntraVascular UltraSound (IVUS) confirmed extensive peri-stent aneurysmal disease involving the diagonal and septal branch ostia. Due to the impossibility of endovascular exclusion of the aneurysm, the case was discussed in a heart team and referred to surgery.
The patient underwent surgical exclusion of the pseudoaneurysm with stent removal and interposition vein graft to the LAD, excluding the septal branch and the diagonal branch from the LAD, bypass grafting of these branches and RCA revascularization using bilateral internal mammary arteries. Postoperative course was complicated by pericardial effusion requiring drainage and non-sustained ventricular tachycardia, with preserved left ventricular function.
Conclusion: The treatment of complicated GCA remains difficult and may lead to coronary rupture. We highlight the advantages of multimodality imaging and the crucial role of individualized hybrid.