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A rare case of a giant saphenous vein graft aneurysm with right atrial fistula formation. A 57-year-old hypertensive and dyslipidaemic man with a history of coronary artery bypass graft 19 years previously, presented with severe exertional angina and dyspnoea despite optimal anti-ischaemic pharmacological therapy and previous percutaneous coronary intervention to the left circumflex artery. CT revealed an aneurysm of the saphenous vein graft to the posterior left ventricular branch of the right coronary artery. The aneurysm had formed a fistulous connection with the right atrium. Initially, luminal reconstruction with serial stents was deemed the most appropriate treatment strategy. However, the procedure was abandoned due to the inability to visualise the graft distal to the aneurysm and the significant shunt to the right atrium. Surgical correction of the right atrial wall defect and replacement of the diseased grafts led to complete resolution of the patient's symptoms.