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A ‘clover’ coronary artery: role of coronary computed tomography to indicate optimal treatment in aneurysmal coronary artery disease

Gorla, Riccardo; Macchi, Andrea; Franzoni, Irene; Spagnolo, Pietro; Margonato, Alberto

Journal of Cardiovascular Medicine: January 2013 - Volume 14 - Issue 1 - p 76–77
doi: 10.2459/JCM.0b013e3283528ffa
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We report the case of a 61-year-old man referred to our department for exertional angina with a history of tri-vessel aneurysmal coronary artery disease. Exercise stress echocardiography was positive for inferior wall hypokinesia. Coronary computed tomography (CT) provided a more accurate characterization of the coronary aneurysms. It detected a laminated thrombus of the proximal left anterior descending and a clover-like aneurysmal dissection of the proximal right coronary artery, which questioned the feasibility of coronary angioplasty. So, the patient was treated with medical therapy only. This case confirmed the importance of coronary CT as diagnostic tool for procedural risk assessment and definition of the most appropriate treatment in patients with coronary aneurysms.

aCardiology Department

bCardiovascular Prevention Center, San Raffaele Hospital, Milan, Italy

Correspondence to Riccardo Gorla, via Olgettina 60, 20132 Milan, ItalyTel: +39 0226437752; fax: +39 0293291315; e-mail: r.gorla@hotmail.it

Received 14 November, 2011

Revised 12 January, 2012

Accepted 7 February, 2012

A 61-year-old man with a history of two acute myocardial infarctions treated conservatively was referred to our department for persistent exertional angina and clinical evaluation.

The last coronary angiography, performed in another hospital 6 months earlier, showed a tri-vessel aneurysmal coronary artery disease (CAD) (Fig. 1a and b), but since the patient, at that time, was mildly symptomatic, he was treated with medical therapy only.

Fig. 1

Fig. 1

Exercise stress echocardiography was positive for inferior wall hypokinesia.

Coronary computed tomography (CT), performed to characterize the aneurysms more accurately and to define coronary angioplasty feasibility, showed a left anterior descending (LAD) proximal aneurysm with a laminated thrombus 4 cm long (Fig. 2a), a circumflex artery proximal occluding calcified stenosis 26 mm long (Fig. 2b) and a right coronary artery (RCA) aneurysmal dilation (maximum diameter of 9 mm) (Fig. 2c) with a clover-like proximal dissection 46 mm long (Fig. 2d), composed of multiple connections between false and true lumen. Three-dimensional volume rendering images confirmed a severe aneurysmal tri-vessel CAD (Fig. 1c and d, Fig. 3).

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Since the procedural risk of RCA perforation and thromboembolic complications was too high, the patient was treated with medical therapy only.

The case confirmed the importance of coronary CT in the management of patients with coronary aneurysms. Unlike coronary angiography, CT provides a more accurate measurement of aneurysm diameter,1 detects the presence and extension of aneurysmal dissections with better evaluation of stenotic lesions,2 and allows the identification and composition analysis of mural thrombi3 in order to establish the embolic risk.

So coronary CT really is a useful tool for procedural risk assessment and definition of the most appropriate treatment in this kind of patient.

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References

1. Michaud L, Cador R, Paul JF, et al. The contribution of computed tomography coronary angiography in Kawasaki disease in adult patients. Report of two cases. Rev Med Interne 2007; 28:526–530.
2. Hasumi E, Iwata H, Saito K, et al. Diagnostic efficacy of coronary CT angiography as a follow-up modality for procedure-related coronary dissection. Int Heart J 2011; 52:240–242.
3. Poulter RS, Younger JF. Cardiac CT imaging for the diagnosis and management of thrombosis in a coronary artery aneurysm. Heart 2011; 97:1028.
Keywords:

coronary aneurysms; coronary artery disease; coronary computed tomography

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