Spontaneous Dissection in Immunoglobulin G4-Related Coronary Arteritis

Name: Spontaneous Dissection in Immunoglobulin G4-Related Coronary Arteritis
Uploaded: 2022-04-29

Jeong Tae Byoun; Seung‐Yul Lee; Jae Young Cho; Kyeong Ho Yun; Seok Kyu Oh

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ID: W4225535756
Title: Spontaneous Dissection in Immunoglobulin G4-Related Coronary Arteritis
Abstract: HomeCirculation: Cardiovascular ImagingVol. 15, No. 5Spontaneous Dissection in Immunoglobulin G4-Related Coronary Arteritis Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBSpontaneous Dissection in Immunoglobulin G4-Related Coronary Arteritis Jeong Tae Byoun, Seung-Yul Lee, Jae Young Cho, Kyeong Ho Yun and Seok Kyu Oh Jeong Tae ByounJeong Tae Byoun Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea. , Seung-Yul LeeSeung-Yul Lee Correspondence to: Seung-Yul Lee, MD, Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, 895, Muwang-ro, Iksan-si, Jeollabuk-do, Korea 54538. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9039-9806 Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea. , Jae Young ChoJae Young Cho https://orcid.org/0000-0001-7972-6223 Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea. , Kyeong Ho YunKyeong Ho Yun https://orcid.org/0000-0003-4911-8854 Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea. and Seok Kyu OhSeok Kyu Oh https://orcid.org/0000-0001-7545-0143 Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea. Originally published29 Apr 2022https://doi.org/10.1161/CIRCIMAGING.122.013958Circulation: Cardiovascular Imaging. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 29, 2022: Ahead of Print As immunoglobulin G4-related disease rarely involves the coronary arteries, the pathomechanism causing myocardial ischemia is not well understood. The present case demonstrates immunoglobulin G4-related coronary arteritis complicated by spontaneous dissection in a patient presenting with acute myocardial infarction.A 62-year-old man visited the emergency room with acute-onset substernal chest pain. Electrocardiography showed ST-segment elevations in leads II, III, and aVF. After the administration of 300 mg aspirin and 180 mg ticagrelor, emergent coronary angiography showed aneurysmal dilation, stenosis, and peri-arterial contrast staining in the proximal-to-mid right coronary artery and thrombotic occlusion in the distal right coronary artery (Video S1). After angioplasty with a 2.0×20-mm balloon, coronary flow was successfully restored to Thrombolysis in Myocardial Infarction flow grade 3. We performed an intravascular ultrasound examination to evaluate the vascular pathology causing acute myocardial infarction. The vascular wall was markedly thickened at the target lesion site without prominent atherosclerosis (Figure 1A and Video S2), and a large burden of thrombi was observed (Figure 1B and Video S2). At the proximal site of the thrombi, a large false lumen was present between the thickened adventitia and the normal-looking media of the arterial wall, indicating spontaneous dissection (Figure 1C and Video S2). Based on these findings, we performed a 3.5-×15-mm SeQuent Please paclitaxel-coated balloon angioplasty (B. Braun, Meslungen, Germany). Final angiography confirmed the success of the procedure (Video S3). Under suspicion of coronary arteritis, coronary computed tomography angiography showed diffuse peri-coronary enhancing lesions surrounding the entire right coronary artery, left main, proximal-to-mid left anterior descending, and proximal left circumflex arteries. Notably, a saccular pseudoaneurysm with remnant thrombus was observed at the lesion site, and a low-attenuation lesion adjacent to the stenosis in the mid-right coronary artery was identified, suggesting intramural thrombosis (Figure 2). Laboratory tests revealed elevated levels of immunoglobulin G4 (1783 mg/dL) and its subclass 4 (1280 mg/dL), consistent with coronary involvement in immunoglobulin G4-related disease.1 Informed consent was obtained from the patient.Download figureDownload PowerPointFigure 1. Intravascular ultrasound (IVUS). The first panel is an angiographic image indicating the location of IVUS images A-C. The arterial wall (arrows) was thickened (A) and a large burden of the thrombi was observed (B). The true lumen (arrowhead) was identified at the proximal segment of thrombi, indicating the coronary dissection (C).Download figureDownload PowerPointFigure 2. Coronary computed tomography angiography. The saccular pseudoaneurysm was observed at the lesion site of the right coronary artery (A) and the thrombus (arrow) remained (B). At the mid portion of the right coronary artery, the low attenuated lesion (arrowheads) was suggestive of intramural thrombus (C and D).Spontaneous coronary artery dissection (SCAD) is characterized by an intramural thrombus within the false lumen of the affected coronary artery.2,3 Although the precise mechanisms are not known, de novo intramural bleeding has been proposed as the outside-in hypothesis for the pathophysiology of SCAD.2,3 In the present case, aneurysmal dilation, stenosis, and peri-arterial contrast staining on angiography were suspicious findings for coronary arteritis, and intravascular ultrasound revealed spontaneous coronary dissection that caused acute myocardial infarction. Coronary computed tomography angiography evaluated the extent of immunoglobulin G4-related coronary arteritis and identified intramural thrombosis, which is the potential pathomechanism of SCAD. Given that inflammatory cell infiltration of the peri-adventitial tissue surrounding the affected coronary artery has often been described as a component of the histopathologic picture of SCAD in autopsy reports,4 the present case simultaneously demonstrates the development and clinical deterioration of SCAD in patients with immunoglobulin G4-related coronary arteritis that usually involves the adventitia of the arterial wall.Article InformationSources of FundingThis article was supported by Wonkwang University in 2022.Supplemental MaterialsVideos S1–S3Disclosures None.FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.122.013958.For Sources of Funding and Disclosures, see page 338.Correspondence to: Seung-Yul Lee, MD, Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, 895, Muwang-ro, Iksan-si, Jeollabuk-do, Korea 54538. Email [email protected]. Umehara H, Okazaki K, Kawa S, Takahashi H, Goto H, Matsui S, Ishizaka N, Akamizu T, Sato Y, Kawano M; Research Program for Intractable Disease by the Ministry of Health, Labor and Welfare (MHLW) Japan. The 2020 Revised Comprehensive Diagnostic (RCD) criteria for IgG4-RD.Mod Rheumatol. 2021; 31:529–533. doi: 10.1080/14397595.2020.1859710CrossrefMedlineGoogle Scholar2. Adlam D, Alfonso F, Maas A, Vrints C; Writing Committee. European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection.Eur Heart J. 2018; 39:3353–3368. doi: 10.1093/eurheartj/ehy080CrossrefMedlineGoogle Scholar3. Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, et al; American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous coronary artery dissection: current state of the science: a scientific statement from the American Heart Association.Circulation. 2018; 137:e523–e557. doi: 10.1161/CIR.0000000000000564LinkGoogle Scholar4. Stone JR. Chapter 8. Diseases of small and medium-sized blood vessels. In: Buja LM, Butany J, eds. Cardiovascular Pathology. 5thedn. Academic Press; 2022:307–351.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2022Vol 15, Issue 5 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.122.013958PMID: 35485242 Originally publishedApril 29, 2022 Keywordsatherosclerosisdissectionarteritisimmunoglobulinmyocardial infarctionPDF download Advertisement SubjectsComputerized Tomography (CT)
Publication Year: 2022
Publication Date: 2022-04-29
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']

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