First described in the literature by Morgagni in 1761, coronary aneurysms remain a rare pathology of the coronary vessels [1] . They are classically defined as a segment of artery whose dilatation exceeds more than one and a half times the diameter of the adjacent healthy portion (considered as the reference point) [1] - [3] . Several etiologies have been described, dominated by atherosclerosis, which is responsible for over 50% of cases described [1] [2] [4] . The pathogenesis remains uncertain [3] . Iatrogenic causes are rare, but are increasingly encountered as a result of complex procedures [5] . The main complications are thrombosis with distal embolization, rupture and vasospasm, leading to myocardial infarction and sudden death [1] [6] . The management of this condition, especially in emergencies, is not clearly codified, depending on the patient’s symptoms and the anatomical presentation of the aneurysm [6] .

We report the case of a 55-year-old female patient referred by her GP for a cardiovascular work-up. Her cardiovascular risk factors included active smoking, dyslipidemia, hypertension and diabetes. She described exertional dyspnea at New York Heart Association (NYHA) stage I, in a context of severe anxiety. Clinical and echocardiographic examination revealed myocardial scintigraphy, which revealed apical ischemia extending across the apical segments of the anterior and septal walls, raising suspicion of damage to the anterior interventricular artery (AIV). Coronary angiography using the 6F right femoral approach revealed chronic occlusion of the proximal right coronary artery (RCA) ( Figure 1 ), with good contralateral anastomosis, and sub occlusion of the proximal AIV ( Figure 2 ). Proximal AIV angioplasty was performed after pre-dilatation of the lesion with a 2.5 mm non-compliant balloon using an everolimus-coated stent (XIENCE SIERRA 3.5 mm × 23 mm) deployed at 12 atmospheres for 20 seconds. The guidewire used was BMW 0.014 HYDRO 3CM J (Abbott). Due to a dissection downstream of the stent, another everolimus-coated stent (XIENCE SIERRA 3.0 × 23 mm) was deployed over this dissection at 14 atmospheres for 22 seconds, using the same BMW guide. As the previous stent had been too short to cover the entire dissected area, another everolimus-coated stent (XIENCE SIERRA 2.5 × 15 mm) was required, implanted adjoining the previous stent and deployed at 12 atmospheres for 20 seconds. The final result was good ( Figure 3 ). Angioplasty of the RCA was performed a second time (10 weeks later) with excellent results ( Figure 4 ). A check of the AIV during the same procedure revealed two simple saccular aneurysmal lesions ( Figure 5 ). These saccular lesions of the middle AIV were treated 8 weeks later with a single PK PAPYRUS 3.0 × 20 mm covered stent with excellent results ( Figure 6 ) through a BMW 0.014 HYDRO 3CM J guide (Abbott). Optimization with a 2.5 mm uncomplicated balloon deployed at 11 atmospheres was performed. A coronary angiogram performed 11 months after implantation of the covered stent showed exclusion of the two aneurysmal lesions ( Figure 7 ). Checks on the RCA revealed no aneurysmal lesion at the same time. Optical Coherence Tomography (OCT) confirmed this exclusion and the good result of the covered stent ( Figure 8 ).

A coronary aneurysm is defined as a dilatation of more than 1.5 times the diameter of the widest coronary artery or normal adjacent segment [1] - [3] . It is a rare condition, with an incidence ranging from 0.2% to 4.9% [1] and a male predominance [3] . Known risk factors include male sex, hypercholesterolemia, smoking and cocaine use [1] .

Coronary aneurysms are most frequently found on the right coronary network, followed by the circumflex artery and the AIV; involvement of the left coronary trunk is rarer [3] [6] - [8] . They may be single or multiple, saccular or fusiform [9] . Because of its iatrogenic aetiology, in our case, saccular aneurysms were found on the AIV.

The pathophysiology remains uncertain. However, some authors suggest the presence of an anomaly in the medial layer of the artery secondary to lipid deposits in the intima [2] [10] . Others suggest that aneurysms are caused by media destruction, thinning of the arterial wall, increased wall stress and progressive dilatation of a segment of the coronary artery [8] [11] . In our case, iatrogenic dissection had weakened the wall, causing segmental dilatation of the artery under pressure.

In the literature, few cases of iatrogenic aneurysms have been described. However, with the advent of coronary angiography and increasingly complex and traumatic coronary angioplasty procedures, iatrogenic coronary aneurysms are likely to develop. The main complications are thrombosis with distal embolization, rupture and vasospasm, leading to myocardial infarction and sudden death [1] [6] . In our case, we proposed a covered stent whose indications are coronary perforation and saccular and fusiform coronary aneurysms [12] .

Classically, a distinction is made between bare stents and, currently, active stents, the aim of which is to reduce the recurrence of immediate, medium- and long-term ischemic events, by counteracting the phenomenon of restenosis and coronary thrombosis [13] . It consists of a wire mesh crimped onto an initially deflated coronary angioplasty balloon. Unlike bare or active stents, covered stents are covered by a synthetic membrane that can exclude a collateral branch [12] [13] . Thus, their use must be cautious and comply with certain rules, namely the absence of significant collateral branches likely to be excluded by the device, the absence of implantation in a bifurcation carina and a longer duration of double platelet anti-aggregation [12] . In our context, the choice of a covered stent was straightforward, given the absence of significant collateral branches and the patient’s low risk of bleeding. The final result at 11 months was excellent.

Our particular case on saccular aneurysm of the acute interventricular artery suggests a management approach to this condition, despite the lack of consensus. Consideration of the existence of an important collateral branch (risk of exclusion) and the risk of bleeding due to the long duration of double anti-aggregation is essential to the choice of treatment. It would also be useful to assess the long-term complications of coronary stents with covered stent implantation.