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Woven coronary artery: A case report and review of literature
International Journal of Cardiology 113 (2006) 121 – 123 www.elsevier.com/locate/ijcard
Letter to the Editor
Woven coronary artery: A case report and review of literature Hurkan Kursaklioglu *, Atila Iyisoy, Turgay Celik Department of Cardiology, Gulhane Military Medical Academy, Etlik, Ankara 06018, Turkey Received 2 August 2005; accepted 6 August 2005 Available online 4 November 2005
Abstract Woven coronary artery is an extremely rare and clearly undefined coronary malformation. Up to now, very few cases have been reported. In this anomaly, epicardial coronary artery are branched into thin channels at any segment of the coronary artery and then these longitudinal twisted thin channels merge again as the main coronary lumen. This anomaly is regarded as a benign condition since there is completely normal blood flow after the distal segment of the abnormal coronary artery. In this case report, we present a 48-year-old male patient with a woven coronary artery anomaly in the circumflex artery and who had been followed up for 5 years. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary artery anomaly; Coronary artery disease; Aortic regurgitation
1. Introduction Woven coronary artery is an extremely rare anomaly and there are only few reported cases until now [1 –4]. In this interesting coronary anomaly, epicardial coronary artery is divided multiple thin channels at any segment of the coronary artery, and subsequently, these multiple channels merge again in order to form the main lumen after twisting along the coronary artery axis. In this report, we describe a case of woven coronary artery anomaly in the circumflex artery.
2. Case report A 48-year-old male patient was referred to our outpatient unit for exertional chest pain on March 2000. In his family history, there was a cardiac by-pass operation on his father. There was a diastolic murmur with a grade of 2 on the third intercostal interval at the left border of the sternum, otherwise normal. The resting 12-lead electrocardiography was within normal limits. Exercise
* Corresponding author. Tel.: +90 312 304 2352; fax: +90 312 304 2352. E-mail address: [email protected] (H. Kursaklioglu). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.08.019
stress test showed 2 mm horizontal ST-segment depression in the inferior leads. Color Doppler echocardiography revealed moderate aortic insufficiency. In light of those finding, the patient underwent coronary angiography. Coronary angiography performed via the right femoral artery with a Judkins’ technique demonstrated a 90% stenosis at the mid-segment of the right coronary artery. Moreover, there was a woven coronary artery anomaly in the circumflex coronary artery. In the mid-segment of the circumflex artery, arterial lumen was divided into multiple thin channels, traversing distally with a twisting course along a nearly 2.5-cm length of coronary segment. Interestingly, a large obtuse marginal branch originated from the anomalous segment. There was a TIMI-III blood flow both at the distal segment and the obtuse marginal branch (Fig. 1a and b). The severe stenosis on the right coronary artery was successfully dilated with a direct stenting. The 6-month control angiography revealed that there was no restenosis in the right coronary artery and still TIMI-III blood flow in the circumflex artery. However, echocardiographic examination showed a severe aortic insufficency in 2005. Preoperative coronary angiography demonstrated that there was no problem in the right coronary artery, and TIMI-III blood flow has been maintained in both the circumflex artery and obtuse marginal artery (Fig. 2a and b). The patient underwent
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anomalous segment. In our patient, positive stress test most probably was caused by the severe stenosis in the right coronary artery not due to the woven coronary anomaly. Woven coronary artery can be accepted as a benign condition. In the case reported by Martuscelli et al. [1], no adverse coronary event occurred during the 4-year followup period. In the present case, we followed up the patient for 5 years. During this follow-up period, woven coronary anomaly in his circumflex artery did not result in any adverse coronary event due to the circumflex artery. TIMIIII blood flow was visualized distal to the anomalous segment in all coronary angiographies of the patient. Hence, just only medical surveillance is enough for the cases with woven coronary anomaly. Although it is very rare, interventional cardiologist should be aware of woven coronary anomaly. Widespread knowledge about woven coronary anomaly prevents unnecessary coronary intervention and medical therapy because of misinterpretation of woven coronary artery as intracoronary thrombus and dissection.
Fig. 1. Woven coronary artery anomaly at the mid-segment of the circumflex artery in the right anterior oblique (a) and lateral (b) projections. There is normal blood flow both at the distal segment of the anomaly and the obtuse marginal branch arising from the anomalous segment.
successful aortic valve operation and he was discharged with no complication.
3. Discussion Few cases of woven coronary artery anomaly have been reported up to now [1– 4]. Woven coronary artery can be defined as a coronary segment showing the twisting course of multiple thin channels along the vessel in any coronary artery with a TIMI-III blood flow distally. This kind of coronary imaging mimics intracoronary thrombus and spontaneous coronary artery dissection. It can proposed that the frequency could have been higher if woven coronary artery had not been misinterpreted as intracoronary thrombus and spontaneous dissection. Some authors thought that this anomaly can be developed from spontaneous dissection, and the twisting of thin channels can cause intracoronary thrombus according to the distance of the anomalous segment [1]. The most interesting point is that the distance of the anomalous segment is limited to several centimeters and it can cause no blood flow limitation. Although woven coronary artery can be found generally in the right coronary artery, it can be also visualized in circumflex artery. The patient with a woven coronary artery anomaly can demonstrate generally normal coronary reserve with a stress test. This is dependent on normal blood flow distal to the
Fig. 2. There is no change in the woven coronary anomaly during the coronary angiography in the right anterior oblique (a) and the left anterior oblique (b) projections after 5 years; and also, it is visualized that normal blood flow is maintained in both the circumflex artery and the obtuse marginal branch arising from the anomalous segment.
H. Kursaklioglu et al. / International Journal of Cardiology 113 (2006) 121 – 123
References [1] Martuscelli E, Romeo F, Giovannini M, Nigri A. Woven coronary artery: differential diagnosis with diffuse intracoronary thrombus. Ital Heart J 2000;1:306 – 7. [2] Sane DC, Vidaillet JH. Woven right coronary artery: a previously undescribed congenital anomaly. Am J Cardiol 1988;61:1158.
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[3] Berman AD, Kim D, Baim DS. Woven right coronary artery: case report and therapeutic implications. Cathet Cardiovasc Diagn 1990;21:258 – 9. [4] Gregorini L, Perondi R, Pomidossi G, Saino A, Bossi IM, Zanchetti A. Woven left coronary artery disease. Am J Cardiol 1995;75:311 – 2.
Letter to the Editor
Woven coronary artery: A case report and review of literature Hurkan Kursaklioglu *, Atila Iyisoy, Turgay Celik Department of Cardiology, Gulhane Military Medical Academy, Etlik, Ankara 06018, Turkey Received 2 August 2005; accepted 6 August 2005 Available online 4 November 2005
Abstract Woven coronary artery is an extremely rare and clearly undefined coronary malformation. Up to now, very few cases have been reported. In this anomaly, epicardial coronary artery are branched into thin channels at any segment of the coronary artery and then these longitudinal twisted thin channels merge again as the main coronary lumen. This anomaly is regarded as a benign condition since there is completely normal blood flow after the distal segment of the abnormal coronary artery. In this case report, we present a 48-year-old male patient with a woven coronary artery anomaly in the circumflex artery and who had been followed up for 5 years. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary artery anomaly; Coronary artery disease; Aortic regurgitation
1. Introduction Woven coronary artery is an extremely rare anomaly and there are only few reported cases until now [1 –4]. In this interesting coronary anomaly, epicardial coronary artery is divided multiple thin channels at any segment of the coronary artery, and subsequently, these multiple channels merge again in order to form the main lumen after twisting along the coronary artery axis. In this report, we describe a case of woven coronary artery anomaly in the circumflex artery.
2. Case report A 48-year-old male patient was referred to our outpatient unit for exertional chest pain on March 2000. In his family history, there was a cardiac by-pass operation on his father. There was a diastolic murmur with a grade of 2 on the third intercostal interval at the left border of the sternum, otherwise normal. The resting 12-lead electrocardiography was within normal limits. Exercise
* Corresponding author. Tel.: +90 312 304 2352; fax: +90 312 304 2352. E-mail address: [email protected] (H. Kursaklioglu). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.08.019
stress test showed 2 mm horizontal ST-segment depression in the inferior leads. Color Doppler echocardiography revealed moderate aortic insufficiency. In light of those finding, the patient underwent coronary angiography. Coronary angiography performed via the right femoral artery with a Judkins’ technique demonstrated a 90% stenosis at the mid-segment of the right coronary artery. Moreover, there was a woven coronary artery anomaly in the circumflex coronary artery. In the mid-segment of the circumflex artery, arterial lumen was divided into multiple thin channels, traversing distally with a twisting course along a nearly 2.5-cm length of coronary segment. Interestingly, a large obtuse marginal branch originated from the anomalous segment. There was a TIMI-III blood flow both at the distal segment and the obtuse marginal branch (Fig. 1a and b). The severe stenosis on the right coronary artery was successfully dilated with a direct stenting. The 6-month control angiography revealed that there was no restenosis in the right coronary artery and still TIMI-III blood flow in the circumflex artery. However, echocardiographic examination showed a severe aortic insufficency in 2005. Preoperative coronary angiography demonstrated that there was no problem in the right coronary artery, and TIMI-III blood flow has been maintained in both the circumflex artery and obtuse marginal artery (Fig. 2a and b). The patient underwent
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H. Kursaklioglu et al. / International Journal of Cardiology 113 (2006) 121 – 123
anomalous segment. In our patient, positive stress test most probably was caused by the severe stenosis in the right coronary artery not due to the woven coronary anomaly. Woven coronary artery can be accepted as a benign condition. In the case reported by Martuscelli et al. [1], no adverse coronary event occurred during the 4-year followup period. In the present case, we followed up the patient for 5 years. During this follow-up period, woven coronary anomaly in his circumflex artery did not result in any adverse coronary event due to the circumflex artery. TIMIIII blood flow was visualized distal to the anomalous segment in all coronary angiographies of the patient. Hence, just only medical surveillance is enough for the cases with woven coronary anomaly. Although it is very rare, interventional cardiologist should be aware of woven coronary anomaly. Widespread knowledge about woven coronary anomaly prevents unnecessary coronary intervention and medical therapy because of misinterpretation of woven coronary artery as intracoronary thrombus and dissection.
Fig. 1. Woven coronary artery anomaly at the mid-segment of the circumflex artery in the right anterior oblique (a) and lateral (b) projections. There is normal blood flow both at the distal segment of the anomaly and the obtuse marginal branch arising from the anomalous segment.
successful aortic valve operation and he was discharged with no complication.
3. Discussion Few cases of woven coronary artery anomaly have been reported up to now [1– 4]. Woven coronary artery can be defined as a coronary segment showing the twisting course of multiple thin channels along the vessel in any coronary artery with a TIMI-III blood flow distally. This kind of coronary imaging mimics intracoronary thrombus and spontaneous coronary artery dissection. It can proposed that the frequency could have been higher if woven coronary artery had not been misinterpreted as intracoronary thrombus and spontaneous dissection. Some authors thought that this anomaly can be developed from spontaneous dissection, and the twisting of thin channels can cause intracoronary thrombus according to the distance of the anomalous segment [1]. The most interesting point is that the distance of the anomalous segment is limited to several centimeters and it can cause no blood flow limitation. Although woven coronary artery can be found generally in the right coronary artery, it can be also visualized in circumflex artery. The patient with a woven coronary artery anomaly can demonstrate generally normal coronary reserve with a stress test. This is dependent on normal blood flow distal to the
Fig. 2. There is no change in the woven coronary anomaly during the coronary angiography in the right anterior oblique (a) and the left anterior oblique (b) projections after 5 years; and also, it is visualized that normal blood flow is maintained in both the circumflex artery and the obtuse marginal branch arising from the anomalous segment.
H. Kursaklioglu et al. / International Journal of Cardiology 113 (2006) 121 – 123
References [1] Martuscelli E, Romeo F, Giovannini M, Nigri A. Woven coronary artery: differential diagnosis with diffuse intracoronary thrombus. Ital Heart J 2000;1:306 – 7. [2] Sane DC, Vidaillet JH. Woven right coronary artery: a previously undescribed congenital anomaly. Am J Cardiol 1988;61:1158.
123
[3] Berman AD, Kim D, Baim DS. Woven right coronary artery: case report and therapeutic implications. Cathet Cardiovasc Diagn 1990;21:258 – 9. [4] Gregorini L, Perondi R, Pomidossi G, Saino A, Bossi IM, Zanchetti A. Woven left coronary artery disease. Am J Cardiol 1995;75:311 – 2.