Medical Image of the Week: Coronary Artery Ectasia

Figure 1. Coronary angiogram demonstrating ectatic right coronary artery (black arrow) with minimal laminar flow of contrast dye. 100% occlusion of distal RCA noted (white arrow), as well as sternotomy wires from prior CABG.

Figure 2. Intravascular ultrasound (IVUS) demonstrating dilated, ectatic right coronary artery with maximum dimension 9-10 mm (white line).

A 70-year-old man with a history of coronary artery disease and previous 3 vessel coronary artery bypass grafting (CABG) was admitted to the coronary care unit with acute chest pain and EKG concerning for ST elevations in II, III, aVF with first degree AV block. Troponins were negative on admission, and peaked at 35 ng/ml. The patient was taken immediately to the cardiac catherization lab for acute inferior ST elevation myocardial infarction (STEMI), and was found to have coronary artery ectasia throughout with diffuse atherosclerotic disease. 100% occlusion was noted in the distal RCA, but the wire was not able to be passed through the blockage due to tortuous and dilated vessels vessels. Left circumflex and left anterior descending arteries showing similar ectatic findings without acute blockage. No stents were able to be engaged in the RCA given the large diameter from the ectasia. The RCA notably had a diameter of 7-10 mm in width with minimal laminar flow of contrast dye (Figure1), and was confirmed with Intravascular Ultrasound (IVUS, Figure 2). Echocardiogram showed an ejection fraction of 55% with normal left ventricular function. Since stents were not able to be placed, the patient was medically optimized with aspirin, ticagrelor, and a high intensity statin. The patient felt improved following medical optimization, and was discharged home in stable condition with cardiology follow up.

Coronary ectasia is a disease of the coronary arteries in which the vessel lumen is increased greater than 1.5 times in size (1). It is a very rare finding, with only 1.2-2% of coronary caths demonstrating ectasia. Clinical findings are believed to be due to increased wall stress and thinning of the arterial wall in the setting of atherosclerosis causing progressive dilation and remodeling (2). Ectasia is also commonly found in patients with connective tissue disease and vasculitis, classically Marfan syndrome and Kawasaki disease. Conventional stents are generally too small in diameter to be utilized. Treatment is largely devoted towards decreasing cardiac risk factors and avoiding medications that slow coronary blood flow such as nitrates (3).

Adam Berlinberg MD¹, Steven Stroud MD¹, Jaren Trost MD¹, Karl Kern MD²

¹Department of Internal Medicine and ²Department of Cardiology, Sarver Heart Center, Banner University Medical Center; Tucson, AZ

References

1. Lin CT, Chen CW, Lin TK, Lin CL. Coronary artery ectasia. Tzu Chi Med J 2008;20:270-4. [CrossRef]
2. Hsu PC, Su HM, Lee HC, Juo SH, Lin TH, Voon WC, Lai WT, Sheu SH. Coronary artery collateral circulation in patients of coronary ectasia with significant coronary artery disease. PLoS One. 2014;9(1): e87001. [CrossRef] [PubMed]
3. Eitan A, Roguin A. Coronary artery ectasia: new insights into pathophysiology, diagnosis, and treatment. Coron Artery Dis 2016;27(5):420-8. [CrossRef] [PubMed] 

Cite as: Berlinberg A, Stroud S, Trost J, Kern K. Medical image of the week: coronary artery ectasia. Southwest J Pulm Crit Care. 2017;14(5):253-4. doi: https://doi.org/10.13175/swjpcc049-17 PDF

Medical Image of the Week: Artery of Percheron Infarction

 

Figure 1. T2 weighted MRI demonstrating bilateral infarcts of the rostral midbrain (A, orange box) and thalami (B, orange box).

 

Figure 2. CT angiogram of posterior cerebral artery circulation demonstrating normal vascularization (A) and artery of Percheron (B, white arrow) (1).

A 55-year-old African-American man presented to the Emergency Department for acute altered mental status which started 4 hours ago. His medical history was significant for heart failure with reduced ejection fraction, diabetes mellitus, marijuana and opioid use. On admission, the patient appeared to be in a deep sleep, unarousable, with grimacing to noxious stimuli. He occasionally moved all extremities. He was intubated for airway protection. Initial CT head non-contrast demonstrated a previous right MCA infarct, with no new acute hemorrhage. MRI/MRA brain revealed complete infarction of the artery of Percheron (AOP), likely due to a left ventricular thrombus (Figure 1). The patient remained somnolent throughout hospitalization with minimal neurologic improvement, and was ultimately transferred to a long-term care facility after a tracheostomy and PEG placement.

The artery of Percheron is a rare, normal intracranial vascular variant in which a single arterial trunk originates from the posterior cerebral artery, giving rise to the vascular supply of both thalami and upper midbrain (Figure 2) (2). Acute occlusion of the artery results in posterior circulation infarction and is associated with impairment of consciousness, sleep and alertness. Diagnosis is usually based on magnetic resonance imaging demonstrating bilateral thalami and midbrain infarct. Management primarily consists of supportive measures, as reperfusion of cerebral microvascular carries significant surgical risk. Given the rarity of incidence, the prognosis of AOP infarct is unknown (3).

TC Ta¹, ET Vo¹, KS Goldlist², B Barcelo¹, JM Dicken³

¹Department of Internal Medicine

²Department of Internal Medicine at University of Arizona at South Campus

³University of Arizona College of Medicine.

University of Arizona

Tucson, AZ USA

References

1. Shetty A, Jones J. Artery of Percheron. Radiopedia. Available at: https://radiopaedia.org/articles/artery-of-percheron (accessed 3/24/17).
2. Lazzaro NA, Wright B, Castillo M, et al. Artery of Percheron infarction: imaging patterns and clinical spectrum. AJNR Am J Neuroradiol. 2010 Aug;31(7):1283-9. [CrossRef] [PubMed]
3. Amin OS, Shwani SS, Zangana HM, Hussein EM, Ameen NA. Bilateral infarction of paramedian thalami: a report of two cases of artery of Percheron occlusion and review of the literature. BMJ Case Rep. 2011 Mar 3;2011. [CrossRef] [PubMed] 

Cite as: Ta TT, Vo ET, Goldlist KS, Barcelo B, Dicken JM. Medical image of the week: artery of Percheron infarction. Southwest J Pulm Crit Care. 2017;14(3):127-8. doi: https://doi.org/10.13175/swjpcc037-17 PDF 

Medical Image of the Week: Endovascular Intervention for Life-threatening Hemoptysis

Video 1. Pre-embolization video showing collateral vessels.

Video 2. Post embolization video showing the endovascular implants and cessation of collateral flow.

Idiopathic pulmonary arterial hypertension (PAH) is an uncommon life threatening disease characterized by a progressive increase in pulmonary vascular resistance with subsequent right ventricular failure and death. Hemoptysis is known to be one of the complications in PAH patients although the exact incidence and mechanism of hemoptysis remains unclear (1,2).

Ours is a case of a 40-year-old woman with known severe idiopathic pulmonary hypertension who was admitted for recurrent episodes of hemoptysis for the past one month. On her first presentation with non-massive hemoptysis, she underwent elective embolization with Amplatzer® vascular plug (St. Jude Medical, St. Paul, MN USA) of the aorto-pulmonary collaterals. These included a large collateral off the right subclavian artery, right internal mammary artery and a large collateral off the descending aorta to the right lung (Video 1). Her hemoptysis resolved. She was admitted seven days’ post first embolization with massive hemoptysis, and immediately underwent repeat embolization with Onyx® (Medtronic, Minneapolis, MN USA), a non-adhesive liquid embolic agent. Embolization was performed on the right intercostal arteries, left bronchial artery, with some abnormal vessels noticed (Video 2).  No active bleeding was visualized during the procedure. Hemoptysis resolved once again.

The management of hemoptysis in patients with PAH remains indeterminate. However, embolization of bronchial arteries has been recommended as an effective method of managing PAH patients with recurrent hemoptysis to control the acute hemorrhage (2,3).

See-Wei Low MBBS¹ Huthayfa Ateeli, MBBS²

¹Department of Medicine and ²Division of Pulmonary, Allergy, Critical Care, and Sleep

Banner University Medical Center

Tucson, AZ, USA

References

1. Broberg C, Ujita M, Babu-Narayan S, Rubens M, Prasad SK, Gibbs JS, Gatzoulis MA. Massive pulmonary artery thrombosis with hemoptysis in adults with Eisenmenger's syndrome: a clinical dilemma. Heart. 2004;90:e63. [CrossRef] [PubMed]
2. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121:789-95. [CrossRef] [PubMed]
3. Reesink HJ, van Delden OM, Kloek JJ, Jansen HM, Reekers JA, Bresser P. Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature. Cardiovasc Intervent Radiol. 2007;30:136-9. [CrossRef] [PubMed] 

Cite as: Low S-W, Ateeli H. Medical image of the week: endovascular intervention for life-threatening hemoptysis. Southwest J Pulm Crit Care. 2017;14(2):86-7. doi: https://doi.org/10.13175/swjpcc017-17 PDF

February 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 49-year-old man presented with complaint of slow worsening of shortness of breath over a period of several months. He was otherwise healthy with no significant past medical history.

Laboratory data, include white blood cell count, coagulation profile, and serum chemistries were within normal limits. Oxygen saturation on room air was 94%.

Frontal and lateral chest radiographs (Figure 1) were performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of nine pages)

1. Frontal and lateral chest radiography shows a right paratracheal mass
2. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
3. Frontal and lateral chest radiography shows left-sided lung nodules
4. Frontal and lateral chest radiography shows lobulated left-sided pleural disease
5. Frontal and lateral chest radiography shows numerous small nodules

Cite as: Gotway MB. February 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(2):73-84. doi: https://doi.org/10.13175/swjpcc020-17 PDF