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A 59-year-old woman, smoker, hypertensive, without a previous history of coronary artery disease referred several episodes of epigastric pain, after exercise electrocardiogram was referred to coronary angiography. It revealed extensive coronary calcification, with a suboccluded left anterior descending (LAD) and a calcified aneurysm of the right coronary artery (RCA), partially filled with thrombus. Coronary-computed tomography showed aneurysmal saccular dilatation of the proximal LAD entirely thrombosed with subocclusion, and a fusiform aneurysm in the proximal RCA, partially thrombosed. The patient was referred for surgical treatment. In our patient, congenital etiology of the aneurysms was unlikely, since the patient did not present congenital heart disease or known genetically inherited disorders. Among acquired aneurysms, the most common cause is represented by atherosclerosis. Other potential causes are connective tissue disorders, trauma, infections, iatrogenic, and Kawasaki syndrome. Usual complications include myocardial ischemia and infarction, embolism, rupture, fistulization, and thrombosis (clearly represented in our case). Current recommendations about management strategies of coronary artery aneurysms (CAAs) are focused on small case series and based on aneurysm's location and morphology, patient's characteristics, and clinical presentation. Medical treatment strategies include antiplatelet therapy or anticoagulant. Other therapeutical options are percutaneous coronary intervention (PCI) and coronary artery bypass graft. In our case, the heart team opted for surgical treatment due to the subocclusion of the proximal LAD and considering stable angina as admitting diagnosis. Moreover, the CAAs were placed in proximal segments, with a large amount of thrombus, so related with high risk for complications if PCI was performed. [ABSTRACT FROM AUTHOR]