A 46-year-old white man presented with a history of multiple myocardial infarctions since the age of 32. Coronary angiography demonstrated severe aneurysmal coronary artery disease. Fourvessel coronary artery bypass grafting (CABG) using bilateral internal mammary arteries and the left radial artery was successfully performed. The differential diagnosis of early onset adult aneurysmal coronary artery disease is discussed, with emphasis on Kawasaki's disease and atherosclerotic coronary artery ectasia. When CABG is indicated, total arterial revascularization should be attempted.