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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 Genc¸1, Ahmet Tas¸tan2, Ahmet Feyzi Abacılar3, Mehmet Bes¸ir 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, S¸ifa University School of Medicine, Izmir, Turkey 2 Department of Cardiology, S¸ifa University School of Medicine, Izmir, Turkey 3 Department of Cardiovascular Surgery, S¸ifa University School of Medicine, Izmir, Turkey
Corresponding author: Berhan Genc¸, MD, Department of Radiology, S¸ifa University, Fevzipas¸a Boulevard No: 172/2, Basmane 35240, Izmir, Turkey. Email: [email protected]
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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
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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, Karc¸aaltıncaba 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 at UNIV TORONTO on November 15, 2015
(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 Genc¸1, Ahmet Tas¸tan2, Ahmet Feyzi Abacılar3, Mehmet Bes¸ir 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, S¸ifa University School of Medicine, Izmir, Turkey 2 Department of Cardiology, S¸ifa University School of Medicine, Izmir, Turkey 3 Department of Cardiovascular Surgery, S¸ifa University School of Medicine, Izmir, Turkey
Corresponding author: Berhan Genc¸, MD, Department of Radiology, S¸ifa University, Fevzipas¸a Boulevard No: 172/2, Basmane 35240, Izmir, Turkey. Email: [email protected]
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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 at UNIV TORONTO on November 15, 2015
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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, Karc¸aaltıncaba 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.
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