what’sthematter iththesecoronar arteries?what’s the matter ... · aortitis, aortic...
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Moderated Complex Case Competition
What’s the matter ith these coronar arteries?What’s the matter with these coronary arteries?
Sang Yeub Lee
Division of Cardiology Department of Internal MedicineDivision of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea
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M/46 chest pain (CCS III) 3 days ago M/46, chest pain (CCS III), 3 days ago
Atherosclerotic risk factor DM/HTN ( / ) Dyslipidemia ( ) Smoking ( )DM/HTN (-/-), Dyslipidemia (-), Smoking (-)
Past medical historyPast medical history Untable angina (+) 6 month ago
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But 6 month ago other hospitalBut 6 month ago, other hospital…
Same chest painSame chest pain
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But 6 month ago other hospital CAG and PCIBut 6 month ago, other hospital… CAG and PCI
RCA os : tight stenosis
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But 6 month ago other hospital CAG and PCIBut 6 month ago, other hospital… CAG and PCI
Predilation with Voyager 3.0X20 mm, Stenting with Biomatrix 3.5X14 mm IVUS: not performed
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6 month later chest pain again!6 month later… chest pain again!
At our hospital ER (Dec. 2010)
l hAggravating exertional chest pain
Chest pain on resting and mild exercise for 3 days p g y
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Baseline labBaseline lab
ER on Dec. 12, 2010
CBC: 6,500/uL-13.4 g/dL-285 K/uL, / g/ /
CPK: 363 IU/L (< 190 IU/L), CK-MB 5.97 ng/mL (<4.94 ng/mL)
Lipid profile: 149 75 52 77 mg/dL fasting glucose: 78 mg/dLLipid profile: 149-75-52-77 mg/dL, fasting glucose: 78 mg/dL
BUN/Cr: 13.5/0.95 mg/dL
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Normal chest X-ray and ECGNormal chest X-ray and ECG
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No RWMA and normal LV EF in echoCG
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Abnoraml Ankle Brachial Index…
pressure drop in Lt arm. p p
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CAG in Dec 2010 (our hospital)CAG in Dec. 2010 (our hospital)
tight stenosis at LM ostiumthe pressure wave was damped
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CAG in Dec 2010 (our hospital)CAG in Dec. 2010 (our hospital)
tight stenosis at RCA ostium and proximal edge of previous stenting sitetight stenosis at RCA ostium and proximal edge of previous stenting site
RCA ostium might be missed in previous stent implantation.
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When I and my colleague saw cine image,y g g ,We went silent…
What’s the matter with these coronary arteries?
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Summary of problemsSummary of problems
Problem listIsolated bilateral coronary ostial stenosis(RCA, LMCA sequential stenosis)N k bl th l i i k f tNo remarkable atherosclerosis risk factors
RCA stenting and ostial restenosisRestenosis ? or missed RCA ostial stent coverageg
Both arm BP difference
Consumptive diagnosis Usual atherosclerotic coronary artery diseaseAortitisAortitis
Rhuematologic vasculitisTakayasu’s arteritisInfectious arteritis
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Clinical Diagnosis, NSTEMI!g ,Tight stenosis in LM ostium!
We decided to perform PCI to LM.
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IVUS – isolated bilateral ostial stenosis IVUS – isolated bilateral ostial stenosis
IVUS after Post balloon dilation : large plaque or tissue burden, CSA stenosis 73%
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Left main ostial stentingLeft main ostial stenting
JL4, 7 Fr sidehole GC, Predilation with Maverick 2.5X15 mm
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Left main ostial stentingLeft main ostial stenting
Stenting with PRO-KINETICS 4.5X15 mmPostdilation with Quantum 4.5X8 mm
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Left main ostial stentingLeft main ostial stenting
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Left main ostial stentingLeft main ostial stenting
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RCA ostium - POBA only and 2 stage PCI -scheduled
POBA with Maverick 2.5X15 mm
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After PCI Additional LaboratoriesAfter PCI, Additional Laboratories
l d bBlood Labhs-CRP: 0.16 mg/dL (< 0.3)ESR: 21 (0~9 mm/hr)ESR: 21 (0~9 mm/hr)c-ANCA: 44 AAU (150~180), p-ANCA: 44 AAU (150~180)FANA: negativeVDRL: reactive (X128), TPA:30.18 positiveFTA-ABS IgM: positive, FTA-ABS IgG: positive
CSF L bCSF LabProtein: 65.3 mg/dL (15~45), Glucose: 61 mg/dL (50~75)WBC: 120 VDRL: reactive (X8)WBC: 120, VDRL: reactive (X8)
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Lab test reveal Lab test reveal…
Tertiary syphilis
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Coronary and Aorta CT-angiographyCoronary and Aorta CT-angiography
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Coronary and Aorta CT-angiographyCoronary and Aorta CT-angiography
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TreatmentTreatment
NSTEMI PCI for biostial lesion
Tertiary syphilis Massive antibiotics
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We really wondered
whether the patient would recover
from ostial stenosis of aortic branch
After MASSIVE ANTIBIOTIC THERAPY
W h k d th F ll CT i hWe checked the Follow up CT angiography
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Follow up CT angiography 4month laterFollow up CT angiography, 4month later
Dec. 2010 April 2011
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Follow up CT angiography 4month laterFollow up CT angiography, 4month later
Dec. 2010 April 2011
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Follow up CT angiography 4month laterFollow up CT angiography, 4month later
Dec. 2010 April 2011
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Follow up 4month laterFollow up, 4month later
• But No chest pain, No other symptom
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Isolated Bilateral Coronary ArteryOstial Stenosis
• atherosclerotic
• Congenitalg
• Radiation exposure
Periaortitis• Periaortitis
– Inflammatory aneurysms
– Tuberculosis
– Syphilis
– non-specific aortitis
– Takayasu's disease
– Kawasaki's disease
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Cardiovascular manifestation of SyphilisCardiovascular manifestation of Syphilis
• Cardiovascular abnormalities are well-known manifestations of tertiary
syphilis infections which although not frequent, are still causes of
morbidity and mortality.
• The cardiovascular manifestations of syphilis compromise asymptomatic
aortitis, aortic regurgitation, coronary ostial stenosis, aortic
aneurysm, and gummatousmyocarditis
• Coronary ostial stenosis can be seen in approximately 26% of the
patients with syphilitic aortitis
• Treatment of IOS in syphilitic aortitiss : CABG, PCI, medical Tx not
confirmed