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The authors present a video of a surgical approach to repair a large right coronary artery (RCA) aneurysm associated with a coronary sinus fistula in a 51-year-old woman. They recommend not simply ligating the fistula, as the ligation could cause an abrupt decrease in coronary flow in the dilated coronary artery, leading to thrombosis and myocardial infarction. The authors advocate performing coronary artery bypass grafting of all branches originating from the aneurysmal RCA that are 1 mm or greater in diameter, in addition to fistula ligation and coronary sinus repair. They used an endoluminal technique to form the anastomoses. Special attention should be paid to the preservation of the conal branch to avoid the risk of ventricular arrhythmias and to determine the adequate length of the saphenous vein graft between sequential anastomoses to avoid tension and kinking. This approach avoids the risk of further enlargement of the coronary artery aneurysm and its potential rupture over time.
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