Asian Cardiovascular and Thoracic Annals

Asian Cardiovascular
and Thoracic Annals
http://aan.sagepub.com/
Thrombosed left circumflex artery aneurysm presenting with myocardial infarction
Berhan Genç, Ahmet Tastan, Ahmet Feyzi Abacilar, Mehmet Besir Akpinar and Samet Uyar
Asian Cardiovascular and Thoracic Annals published online 12 May 2014
DOI: 10.1177/0218492314534846
The online version of this article can be found at:
http://aan.sagepub.com/content/early/2014/05/12/0218492314534846
Published by:
http://www.sagepublications.com
On behalf of:
The Asian Society for Cardiovascular Surgery
Additional services and information for Asian Cardiovascular and Thoracic Annals can be found at:
Email Alerts: http://aan.sagepub.com/cgi/alerts
Subscriptions: http://aan.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - May 12, 2014
What is This?
Downloaded from aan.sagepub.com by guest on June 9, 2014
XML Template (2014)
[2.5.2014–2:48pm]
//blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/140108/APPFile/SG-AANJ140108.3d
(AAN)
[1–3]
[PREPRINTER stage]
Case Study
Thrombosed left circumflex artery
aneurysm presenting with myocardial
infarction
Asian Cardiovascular & Thoracic Annals
0(0) 1–3
ß The Author(s) 2014
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0218492314534846
aan.sagepub.com
Berhan Genç1, Ahmet Taştan2, Ahmet Feyzi Abacılar3,
Mehmet Beşir Akpınar3 and Samet Uyar2
Abstract
Coronary artery aneurysms are life-threatening conditions that are quite uncommon in adults. They are observed in
1.1% to 4.9% of patients undergoing coronary angiography. They are usually located in the right coronary artery, may
sometimes be thrombosed or rupture, and occasionally reach an enormous size leading to compressive symptoms. We
report a case of thrombosed left circumflex artery aneurysm presenting with myocardial infarction. The thrombosed
aneurysm, which could not be clearly demonstrated by coronary angiography, was definitively diagnosed by coronary
computed tomography angiography. No operation was planned owing to total thrombosis of the aneurysm.
Keywords
Coronary aneurysm, coronary thrombosis, coronary vessels, myocardial infarction, tomography, x-ray computed
Introduction
Coronary artery aneurysms are rare and life-threatening cardiovascular conditions. Their incidence in the
general population ranges between 0.02% and 0.04%,
and they are observed in 1.1% to 4.9% of patients
undergoing coronary angiography.1–3 We describe the
case of a patient presenting to our emergency department with chest pain who was diagnosed with myocardial infarction as a result of a thrombosed left
circumflex artery (LCx) aneurysm. The definitive diagnosis could not be made by coronary angiography but
was revealed by cardiac computed tomography (CT)
angiography. To our knowledge, there has been no previously reported case of a thrombosed aneurysm in the
LCx presenting with myocardial infarction.
Case report
A 33-year-old woman presented to our emergency
department with sudden-onset chest pain. Her past history was remarkable for antiepileptic drug therapy
between the ages of 3 to 13 years. On cardiac examination, a 2/6 apical systolic murmur was auscultated.
Her pulse rate was 72 beatsmin 1, blood pressure
120/70 mm Hg, and respiratory rate 22 breathsmin 1.
An electrocardiogram showed ST-segment elevation in
leads II, III, and aVF, consistent with acute inferior
wall myocardial infarction. Cardiac enzymes including
troponin were elevated. A telecardiogram showed a 2.5cm calcified structure superimposed on the heart
shadow. The patient underwent coronary angiography
with an initial diagnosis of acute myocardial infarction.
The LCx had total occlusion of its proximal segment
and a 30 20-mm structure with a calcified wall adjacent to the occluded segment, which was moving synchronously with the heart (Figure 1). CT was obtained
for a definitive diagnosis. It showed patent left anterior
descending and right coronary arteries. There was a
1
Department of Radiology, Şifa University School of Medicine, Izmir,
Turkey
2
Department of Cardiology, Şifa University School of Medicine, Izmir,
Turkey
3
Department of Cardiovascular Surgery, Şifa University School of
Medicine, Izmir, Turkey
Corresponding author:
Berhan Genç, MD, Department of Radiology, Şifa University, Fevzipaşa
Boulevard No: 172/2, Basmane 35240, Izmir, Turkey.
Email: [email protected]
Downloaded from aan.sagepub.com by guest on June 9, 2014
XML Template (2014)
[2.5.2014–2:48pm]
//blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/140108/APPFile/SG-AANJ140108.3d
(AAN)
[1–3]
[PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Figure 1. (a) Coronary angiography showing a lesion with a calcified wall, superimposed on the heart (arrows) and moving
synchronously with it. (b) Selective coronary angiography showing total occlusion of the proximal left circumflex artery (arrow) and
an adjacent calcified lesion (arrow heads).
Figure 2. (a) Volume-rendered cardiac computed tomography angiography showing a 30 20-mm thrombosed aneurysm with a
calcified wall in the proximal portion of the left circumflex artery (arrows). (b) Maximum intensity projection image showing that the
lumen of the aneurysm is thrombosed (white star), but there is contrast material in the distal left circumflex artery due to retrograde
filling (arrows).
30 20-mm fusiform thrombosed aneurysm with a calcified wall in the proximal part of the LCx (Figure 2).
No surgical intervention was scheduled because the
aneurysm was totally thrombosed. The patient was
started on an oral antiplatelet agent and discharged
for outpatient follow-up.
Discussion
A coronary artery aneurysm is defined as a coronary
artery segment that is 1.5–2 times dilated compared
to the adjacent normal coronary artery segment.4
Coronary artery aneurysms are most commonly
observed in descending order of frequency in the right
coronary artery, left anterior descending artery, and left
main coronary artery.2,3 Aneurysm of the LCX is quite
rare. Atherosclerosis is the most common cause of coronary artery aneurysms in adults; other causes include
congenital, infectious, vasculitis, trauma, and coronary
artery interventions.4–6 Coronary aneurysms may rupture or compress adjacent structures when enormously
expanded. There are rare case reports describing large
Downloaded from aan.sagepub.com by guest on June 9, 2014
XML Template (2014)
[2.5.2014–2:49pm]
//blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/140108/APPFile/SG-AANJ140108.3d
(AAN)
[1–3]
[PREPRINTER stage]
Genç et al.
3
aneurysms that led to myocardial infarction secondary
to coronary steal phenomenon or compression. There
are also additional mechanisms, other than the mechanical and functional effects of coronary steal and compression, by which large aneurysms cause myocardial
infarction. The proposed mechanisms include hemodynamic changes within the vessel lumen, leading to
turbulent blood flow or stasis depending on the flow
characteristics. Stasis induces thrombus formation
inside the aneurysmal sac.7
Coronary artery aneurysms can usually be demonstrated by coronary angiography. However, coronary
angiography only provides information related to the
vessel lumen, and fails to completely delineate extraluminal cardiac pathologies. In our case, because the
arterial lumen was completely thrombosed, the thrombosed segment could not be fully assessed. On the other
hand, coronary artery aneurysms can be detected by
both CT and magnetic resonance imaging. CT is preferred, especially in emergency cases, by virtue of a
shorter imaging duration and higher temporal resolution. Multidetector CT is a safe easy-to-use noninvasive tool that allows visualization of other cardiac
structures in addition to the coronary arteries.8,9
Coronary artery variations and pathologies can be evaluated in detail due to the image acquisition and processing properties provided by this modality, including
high temporal resolution multiplanar reconstruction, 3demensional volume rendering, and maximum intensity
projection.
Coronary artery aneurysms may rarely be thrombosed leading to myocardial infarction. When angiography shows a coronary structure with a calcified wall
that continues with an occluded coronary artery segment, one should remember that this appearance may
be due to a calcified coronary artery aneurysm.
Coronary CT angiography is a useful noninvasive technique that can be used for the diagnosis of this rare
condition, even in emergency situations.
Funding
This research received no specific grant from any funding
agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement
None declared.
References
1. Li D, Wu Q, Sun L, et al. Surgical treatment of giant
coronary artery aneurysm. J Thorac Cardiovasc Surg
2005; 130: 817–821.
2. Daoud AS, Pankin D, Tulgan H and Florentin A.
Aneurysms of the coronary artery. Report of ten
cases and review of literature. Am J Cardiol 1963; 11:
228–237.
3. Swanton RH, Thomas ML, Coltart DJ, Jenkins BS,
Webb-Peploe MM and Williams BT. Coronary artery
ectasia—a variant of occlusive coronary atherosclerosis.
Br Heart J 1978; 40: 393–400.
4. Syed M and Lesch M. Coronary artery aneurysm: a
review. Prog Cardiovasc Dis 1997; 40: 77–84.
5. Jha NK, Ouda HZ, Khan JA, Eising GP and Augustin N.
Giant right coronary artery aneurysm—case report and
literature review. J Cardiothorac Surg 2009; 4: 18.
6. Pahlavan PS and Niroomand F. Coronary artery aneurysm: a review. Clin Cardiol 2006; 29: 439–443.
7. Chauhan A, Musunuru H, Hallett RL, Walsh M, Szabo S
and Halloran W. An unruptured, thrombosed 10 cm right
coronary artery aneurysm mimicking a pericardial cyst.
J Cardiothorac Surg 2013; 7;8: 2.
8. Kantarcı M, Doganay S, Karçaaltıncaba M, et al. Clinical
situations in which coronary CT angiography confers superior diagnostic information compared with
coronary angiography. Diagn Interv Radiol 2012; 18:
261–269.
9. Aviram G, Loberman D, Herz I, Uretzky G, Graif M and
Roth A. Images in cardiovascular medicine. Thrombosis
of a coronary artery aneurysm in a young man presenting
with acute myocardial infarction. Circulation 2004; 110:
e448–e449.
Downloaded from aan.sagepub.com by guest on June 9, 2014