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Coronary artery dissection following angioplasty detected by multi-detector row computed tomography: Evaluation using the Plaque Map system
International Journal of Cardiology 115 (2007) 404 – 405 www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary artery dissection following angioplasty detected by multi-detector row computed tomography: Evaluation using the Plaque Map system Sei Komatsu a,⁎, Yosuke Omori a , Atsushi Hirayama a , Yuichi Sato b , Yasuo Fujisawa c , Masayoshi Kiyomoto c , Yutaka Koshimune c , Susumu Tagai c , Takuya Amakawa c , Kazuhisa Kodama a a
Cardiovascular Division, Osaka Police Hospital, Kitayama-cho 10-31, Tennoji-ku, Osaka, 543-8502, Japan b Department of Cardiology, Nihon University School of Medicine, Tokyo, Japan c Department of Radiological Technology, Osaka Police Hospital, Osaka, Japan Received 25 November 2005; accepted 9 January 2006 Available online 4 August 2006
Keywords: Coronary artery dissection; Multidetector row computed tomography; Plaque map; Angioplasty
1. Case report A 63-year-old woman was admitted to our hospital complaining with orthopnea. She had a history of myocardial infarction 1 year ago. Her ECG showed ST elevation on leads II, III, and aVF, and q waves on left precordial leads. She was diagnosed as having acute inferior myocardial infarction and acute heart failure. Emergent coronary catheterization was performed. Coronary angiogram revealed an occlusion in the ostial portion of the right coronary artery without significant stenosis in the left coronary arteries. Insertion of the guide wire into the occluded right coronary artery was repeatedly performed, but the guide wire did not advance to the midportion of the right coronary artery. As a result, dissection with an intimal flap occurred in the right aortic cusp with no contrast opacification in the right coronary artery (Fig. 1A) and the interventional procedure was discontinued. After treatment for acute heart failure for a month, the second coronary angiography was performed. The distal portion of right coronary artery was contrast-enhanced through the pseudo-lumen (Fig. 1B, white arrow). For the further morphological assessment, 16-detector-row computed tomography (MDCT) was performed using a LightSpeed 16 ⁎ Corresponding author. Tel.: +81 6 6771 6051; fax: +81 6 6775 2845. E-mail address: [email protected] (S. Komatsu). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.01.058
(GE Systems, USA) with the slice thickness of 0.625 mm; pitch of 0.3: 1; rotation time of 0.5 s; and the trigger point of 70–80% R–R. The 80 ml of contrast medium (Optiray 320; Tyco Healthcare Co., Ltd, Japan) was used. The curved multiplanar reformation image showed an intimal flap in the right coronary artery (Fig. 2A, black arrow). Cross-sectional multiplanar reformation images of the proximal portion of the right coronary artery at 1 mm intervals (Fig. 2B) were converted into Plaque Map [1] and consecutive images were demonstrated (Fig. 2C). An intimal flap which discriminated the true lumen (Fig. 2C, black dotted arrows) from the pseudo-lumen (Fig. 2C, black arrows) was clearly demonstrated by Plaque Map. Since there was no evidence of ischemia, she was treated medically. 2. Discussion Coronary artery dissection is one of the serious complications of percutaneous coronary intervention procedure. To our knowledge, this is the first report demonstrating MDCT findings of coronary artery dissection induced by percutaneous coronary intervention. With its excellent spatial resolution, MDCT provides information of coronary artery stenosis [2] and anomaly [3,4]. Our report suggested that MDCT also has potential to diagnose coronary artery dissection by depicting the intimal flap which discriminated
S. Komatsu et al. / International Journal of Cardiology 115 (2007) 404–405
405
Fig. 1. (A) Coronary angiogram of right coronary artery in the left oblique 45° projection in acute phase. Coronary dissection and an occlusion at the proximal portion. Flap of right aortic cusp was demonstrated (showed as arrows). (B) Coronary angiogram of right coronary artery in the left oblique 45° projection in chronic stage. Spontaneous recanalization was demonstrated via pseudo-lumen on the middle of right coronary artery.
Fig. 2. (A) Coronary MDCT angiogram of right coronary artery in the left oblique 45° projection in chronic stage. Coronary dissection and flap of right aortic cusp was demonstrated. The true lumen (T) and the false lumen (F) were shown. (B) Consecutive images of Plaque Map of the proximal portion of right coronary artery. Cross-sectional images of coronary artery were at 1 mm interval. Pseudo-lumen was demonstrated as black arrows and true lumen was demonstrated as black dotted arrows. Calcified plaque (showed as red and gray area) might mislead a guide wire to pseudo-lumen.
the false lumen from the true lumen. We have demonstrated previously that the Plaque Map system by which CT densities are converted into color gradations allows visual characterization of the coronary artery plaque texture [1]. In our patient, the Plaque Map system was also useful in the diagnosis of coronary artery dissection. References [1] Komatsu S, Hirayama A, Omori Y, et al. Detection of coronary plaque by computed tomography with a novel plaque analysis system, ‘Plaque
Map’, and comparison with intravascular ultrasound and angioscopy. Circ J 2005;69:72–7. [2] Hoffmann MH, Shi H, Schmitz BL, et al. Noninvasive coronary angiography with multislice computed tomography. JAMA 2005;293: 2471–2478. [3] Sato Y, Inoue F, Matsumoto N, et al. Detection of anomalous origins of the coronary artery by means of multislice computed tomography. Circ J 2005;69:320–4. [4] Ichikawa M, Komatsu S, Asanuma H, et al. Acute myocardial infarction due to a “malignant” anomalous right coronary artery detected by multidetector row computed tomography. Circ J 2005;69:1564–7.
Letter to the Editor
Coronary artery dissection following angioplasty detected by multi-detector row computed tomography: Evaluation using the Plaque Map system Sei Komatsu a,⁎, Yosuke Omori a , Atsushi Hirayama a , Yuichi Sato b , Yasuo Fujisawa c , Masayoshi Kiyomoto c , Yutaka Koshimune c , Susumu Tagai c , Takuya Amakawa c , Kazuhisa Kodama a a
Cardiovascular Division, Osaka Police Hospital, Kitayama-cho 10-31, Tennoji-ku, Osaka, 543-8502, Japan b Department of Cardiology, Nihon University School of Medicine, Tokyo, Japan c Department of Radiological Technology, Osaka Police Hospital, Osaka, Japan Received 25 November 2005; accepted 9 January 2006 Available online 4 August 2006
Keywords: Coronary artery dissection; Multidetector row computed tomography; Plaque map; Angioplasty
1. Case report A 63-year-old woman was admitted to our hospital complaining with orthopnea. She had a history of myocardial infarction 1 year ago. Her ECG showed ST elevation on leads II, III, and aVF, and q waves on left precordial leads. She was diagnosed as having acute inferior myocardial infarction and acute heart failure. Emergent coronary catheterization was performed. Coronary angiogram revealed an occlusion in the ostial portion of the right coronary artery without significant stenosis in the left coronary arteries. Insertion of the guide wire into the occluded right coronary artery was repeatedly performed, but the guide wire did not advance to the midportion of the right coronary artery. As a result, dissection with an intimal flap occurred in the right aortic cusp with no contrast opacification in the right coronary artery (Fig. 1A) and the interventional procedure was discontinued. After treatment for acute heart failure for a month, the second coronary angiography was performed. The distal portion of right coronary artery was contrast-enhanced through the pseudo-lumen (Fig. 1B, white arrow). For the further morphological assessment, 16-detector-row computed tomography (MDCT) was performed using a LightSpeed 16 ⁎ Corresponding author. Tel.: +81 6 6771 6051; fax: +81 6 6775 2845. E-mail address: [email protected] (S. Komatsu). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.01.058
(GE Systems, USA) with the slice thickness of 0.625 mm; pitch of 0.3: 1; rotation time of 0.5 s; and the trigger point of 70–80% R–R. The 80 ml of contrast medium (Optiray 320; Tyco Healthcare Co., Ltd, Japan) was used. The curved multiplanar reformation image showed an intimal flap in the right coronary artery (Fig. 2A, black arrow). Cross-sectional multiplanar reformation images of the proximal portion of the right coronary artery at 1 mm intervals (Fig. 2B) were converted into Plaque Map [1] and consecutive images were demonstrated (Fig. 2C). An intimal flap which discriminated the true lumen (Fig. 2C, black dotted arrows) from the pseudo-lumen (Fig. 2C, black arrows) was clearly demonstrated by Plaque Map. Since there was no evidence of ischemia, she was treated medically. 2. Discussion Coronary artery dissection is one of the serious complications of percutaneous coronary intervention procedure. To our knowledge, this is the first report demonstrating MDCT findings of coronary artery dissection induced by percutaneous coronary intervention. With its excellent spatial resolution, MDCT provides information of coronary artery stenosis [2] and anomaly [3,4]. Our report suggested that MDCT also has potential to diagnose coronary artery dissection by depicting the intimal flap which discriminated
S. Komatsu et al. / International Journal of Cardiology 115 (2007) 404–405
405
Fig. 1. (A) Coronary angiogram of right coronary artery in the left oblique 45° projection in acute phase. Coronary dissection and an occlusion at the proximal portion. Flap of right aortic cusp was demonstrated (showed as arrows). (B) Coronary angiogram of right coronary artery in the left oblique 45° projection in chronic stage. Spontaneous recanalization was demonstrated via pseudo-lumen on the middle of right coronary artery.
Fig. 2. (A) Coronary MDCT angiogram of right coronary artery in the left oblique 45° projection in chronic stage. Coronary dissection and flap of right aortic cusp was demonstrated. The true lumen (T) and the false lumen (F) were shown. (B) Consecutive images of Plaque Map of the proximal portion of right coronary artery. Cross-sectional images of coronary artery were at 1 mm interval. Pseudo-lumen was demonstrated as black arrows and true lumen was demonstrated as black dotted arrows. Calcified plaque (showed as red and gray area) might mislead a guide wire to pseudo-lumen.
the false lumen from the true lumen. We have demonstrated previously that the Plaque Map system by which CT densities are converted into color gradations allows visual characterization of the coronary artery plaque texture [1]. In our patient, the Plaque Map system was also useful in the diagnosis of coronary artery dissection. References [1] Komatsu S, Hirayama A, Omori Y, et al. Detection of coronary plaque by computed tomography with a novel plaque analysis system, ‘Plaque
Map’, and comparison with intravascular ultrasound and angioscopy. Circ J 2005;69:72–7. [2] Hoffmann MH, Shi H, Schmitz BL, et al. Noninvasive coronary angiography with multislice computed tomography. JAMA 2005;293: 2471–2478. [3] Sato Y, Inoue F, Matsumoto N, et al. Detection of anomalous origins of the coronary artery by means of multislice computed tomography. Circ J 2005;69:320–4. [4] Ichikawa M, Komatsu S, Asanuma H, et al. Acute myocardial infarction due to a “malignant” anomalous right coronary artery detected by multidetector row computed tomography. Circ J 2005;69:1564–7.