Yeungnam Univ J Med.  2018 Jun;35(1):121-126. 10.12701/yujm.2018.35.1.121.

Multi-vessel intractable coronary spasm development in a patient with aborted sudden cardiac death: a case study with intravascular ultrasound findings

• Cho S
• Kang TS

• KMID: 2415745
• DOI: http://doi.org/10.12701/yujm.2018.35.1.121

Abstract

Coronary spasm generally occurs in patients with minimal atherosclerotic plaque lesion, and it has a rather favorable prognosis. However, in some cases, coronary spasm may induce myocardial infarction and even sudden cardiac death (SCD). Here, we report a case in which multi-vessel intractable coronary vasospasm suddenly occurred in a diffuse atherosclerotic lesion after percutaneous coronary intervention (PCI) in a patient with aborted SCD. We identified the characteristics of the spasm portion in intravascular ultrasound (IVUS) images and conducted percutaneous cardiopulmonary bypass support-PCI with stenting as treatment. Intima and media thickening and a large attenuated plaque burden with rupture were identified in IVUS images at the obstructive spasm portion.

Keyword

Coronary vasospasm; Intravascular ultrasound; Sudden cardiac death

MeSH Terms

Cardiopulmonary Bypass
Coronary Vasospasm
Death, Sudden, Cardiac*
Humans
Myocardial Infarction
Percutaneous Coronary Intervention
Plaque, Atherosclerotic
Prognosis
Rupture
Spasm*
Stents
Ultrasonography*

Figure

• 

  Fig. 1. Coronary angiography. (A) Initial left coronary angiography showing the significant stenosis of proximal LAD artery ostial lesion (white arrow). (B) Initial right coronary angiography showing the discrete significant stenosis of distal RCA (white arrow). *Coronary angiography after intracoronary nitrate injection. (C) Left coronary angiography after PCI and stenting at proximal LAD (white arrow). (D) Right coronary angiography after PCI and stenting at distal RCA (white arrow). LAD, left anterior descending; RCA, right coronary artery; PCI, percutaneous coronary intervention.

• 

  Fig. 2. Intravascular ultrasound. (A) Pre-intervention IVUS showing the eccentric echodense plaque with severe luminal narrowing at proximal LAD (white arrow), and there was not seen severe stenosis or plaque rupture at proximal LCx coronary artery (yellow arrow). (B) Post-intervention IVUS from distal LM to proximal LAD (white arrow: LAD and yellow arrow: LCx). LAD, left anterior descending; LCx, left circumflex; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention.

• 

  Fig. 3. Right coronary angiography and IVUS after spasm development. (A) Total occlusion of proximal RCA due to severe spasm (white arrow). (B) IVUS after resolved spasm after intracoronary nicorandil injection shows diffuse intima- and media-thickening with large amount of atheromatous plaque (yellow arrow) at mid RCA, and large attenuated plaque and prominent intima-thickening with rupture (white arrow) at proximal RCA. (C) PCI and stenting at proximal RCA (white arrow). RCA, right coronary artery; IVUS, intravascular ultrasound; PCI, percutaneous coronary intervention.

• 

  Fig. 4. Left coronary angiography after shock and recurrence AV block. (A) Total occlusion of proximal LCx artery due to severe spasm(white arrow). (B) Spasm resolved after intracoronary nicorandil injection (white arrow). AV, atrioventricular; LCx, left circumflex.

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  Fig. 5. Right coronary angiography after PCPS. (A) Total occlusion of mid RCA due to severe spasm (black arrow). (B) Spasm not fully resolved after several intracoronary nicorandil injections. (C) Mechanically breaking the spasm by stenting at mid RCA (black arrow). PCPS, percutaneous cardiopulmonary bypass support; RCA, right coronary artery.

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