Author + information
- Received August 10, 2017
- Revision received September 20, 2017
- Accepted October 10, 2017
- Published online January 17, 2018.
- Dai Yuxiang, MD,
- Zhang Feng, MD,
- Qian Juying, MD, PhD and
- Ge Junbo, MD, PhD∗ ()
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
- ↵∗Address for correspondence:
Dr. Ge Junbo, No. 1609, Xietu Road, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
A 36-year-old man underwent surgical closure of a left coronary-to-right ventricle fistula in 2000. At that time the left main coronary artery (LM) was enlarged (14 mm). In 2004, a giant aneurysm of LM was demonstrated during angiography (Figure 1A), and the patient underwent coronary artery bypass grafting for severe slow flow in the left anterior descending artery (LAD). Coronary computed tomography angiogram performed in 2009 showed patency of grafts and the giant aneurysm (Figure 1B).
In October 2016, the patient was admitted for chest pain, and emergent angiography revealed total occlusion of the LM (Figure 1C). After numerous rounds of percutaneous thrombus aspiration, a large amount of thrombus was withdrawn and flow to the left circumflex was restored. Extensive thrombus remained in the giant aneurysm (Figure 1C). Echocardiography also showed thrombus in the dilated LAD (Figure 1D). Enhanced antithrombotic therapy including glycoprotein IIb/IIIa inhibitors for 48 hours, aspirin 100 mg/day, clopidogrel 75 mg/day, and warfarin (dosage according to international normalized ratio, 2 to 3) was used after the procedure. Re-examination via coronary computed tomography angiogram (Figure 1E), coronary angiography, and intravascular ultrasound (Figure 1F) in June 2017 showed patency of LM and left circumflex.
This is an unusual report of thrombotic occlusion of a giant aneurysm of LM after surgical closure of a coronary fistula. Fistulae may be the main cause of the coronary aneurysm, which extended from the LM to the mid-LAD. Slow flow in the LAD may have contributed to thrombus formation in proximal LAD, and this extended into the LM after coronary artery bypass grafting. Enhanced antithrombotic therapy may be useful to maintain the patency of the distal segment of the aneurysm for this patient (1,2).
This study was supported by the National Natural Science Foundation of China (No. 81300095). All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 10, 2017.
- Revision received September 20, 2017.
- Accepted October 10, 2017.
- 2018 American College of Cardiology Foundation
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