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.
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).
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.
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
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
3. Poulter RS, Younger JF. Cardiac CT imaging for the diagnosis and management of thrombosis in a coronary artery aneurysm. Heart