Coronary arteritis: a case series

Shinnosuke Kikuchi, Kozo Okada, Kiyoshi Hibi, Nobuhiko Maejima, Naoto Yabu, Keiji Uchida, Kouichi Tamura, Kazuo Kimura, Shinnosuke Kikuchi, Kozo Okada, Kiyoshi Hibi, Nobuhiko Maejima, Naoto Yabu, Keiji Uchida, Kouichi Tamura, Kazuo Kimura

Abstract

Background: The present article describes two cases of patients with coronary arteritis (CA) whose identification of CA diagnosis (late vs. early) resulted in different clinical courses and outcomes.

Case summary: Case 1 is a 53-year-old woman with multiple coronary risk factors who was admitted with acute coronary syndrome (ACS) and significant stenosis in the left main trunk (LMT). Although clues suggested arteritis (LMT lesion without any other stenosis, occlusion of left internal thoracic artery, etc.), the diagnosis of CA (coronary involvement of unclassified arteritis) was delayed and revascularization, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), was performed under uncontrolled inflammatory status. As a result, Case 1 experienced repeated ACS episodes due to graft failure and in-stent restenosis, and repeatedly underwent PCI. Case 2 is a 76-year-old woman with no significant coronary risk factors who was admitted with ACS. This patient was successfully diagnosed with coronary involvement of Takayasu arteritis before revascularization. Coronary artery bypass grafting was performed after stabilizing inflammation with prednisolone, and the patient remains angina-free beyond 1-year post-CABG. In both cases, intravascular imaging clearly identified the localization and degree of inflammation related to CA by demonstrating specific findings (ambiguous typical three-layer structure of arterial wall and extended low-echoic areas within adventitia).

Discussion: Accurate and early diagnosis with meticulous diagnostic and therapeutic strategies appear to be important for favourable clinical outcomes in the medical treatment of patients with coronary involvement of arteritis. Intravascular imaging has the potential to contribute to optimizing clinical management of CA.

Keywords: Case series; Coronary arteritis; Coronary computed tomography angiography; Intracoronary imaging; Takayasu arteritis; Unclassified arteritis.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Coronary angiogram and intracoronary imaging findings of Case 1. (A and B) Coronary angiogram demonstrated severe in-stent restenosis with remarkable proliferated neovascularization around the stented segment (white circle and white arrowheads) in distal left main trunk to ostium of left anterior descending artery and left circumflex coronary artery. (C) Optical coherence tomography revealed multiple microvessels communicating with lumen (white arrows) and peri-strut low intensity area (black arrowheads) within neointima. (D–F) Intravascular ultrasound showed ambiguous three-layered structure within the stented and non-stented segments (D), and various degrees of peri-arterial low-echoic area and peri-arterial small vessels (yellow arrows) within stents and near distal stent edge (E). In contrast, these findings were not apparent in distal left anterior descending artery (F). CAG, coronary angiography; IVUS, intravascular ultrasound; LAD, left anterior descending artery; LCX, left circumflex coronary artery; LMT, left main trunk; OCT, optical coherence tomography; PLEA, peri-arterial low-echoic area.
Figure 2
Figure 2
Computed tomography, computed tomography angiography, and positron emission tomography–computed tomography findings of Case 2. (A) No significant stenosis was observed in left anterior descending artery. (B) Significant stenosis was observed in left circumflex coronary artery. (C) Significant stenosis with aneurysm was observed in mid-right coronary artery. (D) Significant stenosis with calcification was observed in left main trunk. (E) Concentric wall thickening of the ascending aorta was observed. (F) Plain computed tomography showed concentric thickened high-attenuation wall of ascending aorta. (G) Contrast-enhanced computed tomography showed that the thickened wall appeared with low-attenuation. (H) Delayed phase contrast-enhanced computed tomography showed ‘double ring enhancement’ (black arrowheads). (I) Positron emission tomography–computed tomography revealed increased F-18 fluorodeoxyglucose uptake in the wall of ascending aorta, especially a part of ‘double ring enhancement’ (red arrowheads). CAG, coronary angiography; CT, computed tomography; CTA, computed tomography angiography; IVUS, intravascular ultrasound; LAD, left anterior descending artery; LCX, left circumflex coronary artery; LMT, left main trunk; OCT, optical coherence tomography; PET, positron emission tomography; PLEA, peri-arterial low-echoic area; RCA, right coronary artery.
Figure 3
Figure 3
Intravascular ultrasound findings of Case 2. (A and B) Intravascular ultrasound revealed obscured three-layered structure and peri-arterial low-echoic area (white arrows) in left main trunk. (C) Peri-arterial low-echoic area (white arrows) was observed at the site of mild plaque in mid-left anterior descending artery segment. (D) On PET-CT, there was increased F-18 fluorodeoxyglucose uptake in left main trunk where abnormal IVUS findings were seen. CT, computed tomography; IVUS, intravascular ultrasound; LAD, left anterior descending artery; LCX, left circumflex coronary artery; LMT, left main trunk; PET, positron emission tomography.
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/7180521/bin/ytaa011f4.jpg

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Source: PubMed

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