Canadian Journal of Cardiology
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(2014) 1.e1e1.e2 www.onlinecjc.ca
Letters to the Editor Spontaneous Coronary Artery Dissection and Fibromuscular Dysplasia We read with great interest the recently published review article by Saw that described epidemiology, associated etiology, diagnosis, management, and outcome of patients with spontaneous coronary artery dissection (SCAD).1 As the author described, SCAD is a frequent, albeit underdiagnosed, condition that is seen especially in women without apparent traditional risk factors. In addition, Saw et al. showed that fibromuscular dysplasia (FMD) is frequently associated with SCAD, suggesting that FMD in coronary arteries may predispose to dissection of the coronary artery.2 It is possible the clinical course and optimal treatment strategies for this specific form of coronary artery disease might differ from usual atherosclerotic coronary artery lesions; however, FMD may more often manifest in noncoronary arteries than in coronary arteries per se; therefore, we should not overlook such arterial lesions that may demonstrate a “string of beads” appearance. Saw listed the renal, iliac, and cerebrovascular arteries as common noncoronary locations for of FMD.1 Recently, we incidentally encountered a patient who had FMD of the bilateral brachial artery, as described here. A 54-year-old woman was referred to our hospital as a result of sudden chest pain suggestive of acute coronary syndrome. Coronary artery angiography showed long-segment narrowing and irregularity of the left circumflex artery; spontaneous coronary artery dissection was diagnosed (Fig. 1A, arrows). Successful revascularization was obtained by balloon angioplasty using the femoral artery approach. At the time of follow-up, a second angiographic procedure was
performed using a brachial artery approach, at which time a residual intimal tear of the dilated region (Fig. 1B, arrow) was observed. We encountered tortuosity while accessing the left brachial artery, and subsequent angiography demonstrated a moniliform string of beads appearance of the artery, consistent with FMD (Fig. 1C). Three days later, contrast enhancement of the right brachial artery was performed without passing either a guiding catheter or a guide wire into the artery; again a string of beads appearance of the right brachial artery was seen (Fig. 1D). The brachial artery was reported to be an uncommon site affected by FMD,3 yet the prevalence of such lesions may again be underdiagnosed. Because the radial approach is being increasingly used for angiography, angiographers should be more cognizant of this condition especially when imaging patients with SCAD, and if difficult assessment of the brachial artery is encountered during angiography, imaging of the brachial artery should be performed to assess for FMD. Nobukazu Ishizaka, MD [email protected] Suguru Tanaka, MD Jun Tanigawa, MD Hideaki Morita, MD
Disclosures The authors have no conflicts of interest to disclose.
Figure 1. Angiography of the coronary and brachial arteries. (A) Before coronary artery intervention. Severe luminal stenosis and (presumable) coronary dissection are observed at the branch of the left circumflex artery (arrows). (B) Coronary angiography 6 days after balloon angioplasty. Intimal tear is observed (arrow). The left (C) and right (D) brachial arteries. An arterial wall irregularity compatible with fibromuscular dysplasia was observed.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.01.010
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References 1. Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013;29: 1027-33. 2. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including
Canadian Journal of Cardiology Volume - 2014 fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6:44-52. 3. Lewis DR, Buckenham T, Yeo YE. Medical image. A rare case of brachial artery fibromuscular dysplasia (FMD). N Z Med J 2011;124: 114-5.
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(2014) 1.e1e1.e2 www.onlinecjc.ca
Letters to the Editor Spontaneous Coronary Artery Dissection and Fibromuscular Dysplasia We read with great interest the recently published review article by Saw that described epidemiology, associated etiology, diagnosis, management, and outcome of patients with spontaneous coronary artery dissection (SCAD).1 As the author described, SCAD is a frequent, albeit underdiagnosed, condition that is seen especially in women without apparent traditional risk factors. In addition, Saw et al. showed that fibromuscular dysplasia (FMD) is frequently associated with SCAD, suggesting that FMD in coronary arteries may predispose to dissection of the coronary artery.2 It is possible the clinical course and optimal treatment strategies for this specific form of coronary artery disease might differ from usual atherosclerotic coronary artery lesions; however, FMD may more often manifest in noncoronary arteries than in coronary arteries per se; therefore, we should not overlook such arterial lesions that may demonstrate a “string of beads” appearance. Saw listed the renal, iliac, and cerebrovascular arteries as common noncoronary locations for of FMD.1 Recently, we incidentally encountered a patient who had FMD of the bilateral brachial artery, as described here. A 54-year-old woman was referred to our hospital as a result of sudden chest pain suggestive of acute coronary syndrome. Coronary artery angiography showed long-segment narrowing and irregularity of the left circumflex artery; spontaneous coronary artery dissection was diagnosed (Fig. 1A, arrows). Successful revascularization was obtained by balloon angioplasty using the femoral artery approach. At the time of follow-up, a second angiographic procedure was
performed using a brachial artery approach, at which time a residual intimal tear of the dilated region (Fig. 1B, arrow) was observed. We encountered tortuosity while accessing the left brachial artery, and subsequent angiography demonstrated a moniliform string of beads appearance of the artery, consistent with FMD (Fig. 1C). Three days later, contrast enhancement of the right brachial artery was performed without passing either a guiding catheter or a guide wire into the artery; again a string of beads appearance of the right brachial artery was seen (Fig. 1D). The brachial artery was reported to be an uncommon site affected by FMD,3 yet the prevalence of such lesions may again be underdiagnosed. Because the radial approach is being increasingly used for angiography, angiographers should be more cognizant of this condition especially when imaging patients with SCAD, and if difficult assessment of the brachial artery is encountered during angiography, imaging of the brachial artery should be performed to assess for FMD. Nobukazu Ishizaka, MD [email protected] Suguru Tanaka, MD Jun Tanigawa, MD Hideaki Morita, MD
Disclosures The authors have no conflicts of interest to disclose.
Figure 1. Angiography of the coronary and brachial arteries. (A) Before coronary artery intervention. Severe luminal stenosis and (presumable) coronary dissection are observed at the branch of the left circumflex artery (arrows). (B) Coronary angiography 6 days after balloon angioplasty. Intimal tear is observed (arrow). The left (C) and right (D) brachial arteries. An arterial wall irregularity compatible with fibromuscular dysplasia was observed.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.01.010
1.e2
References 1. Saw J. Spontaneous coronary artery dissection. Can J Cardiol 2013;29: 1027-33. 2. Saw J, Ricci D, Starovoytov A, Fox R, Buller CE. Spontaneous coronary artery dissection: prevalence of predisposing conditions including
Canadian Journal of Cardiology Volume - 2014 fibromuscular dysplasia in a tertiary center cohort. JACC Cardiovasc Interv 2013;6:44-52. 3. Lewis DR, Buckenham T, Yeo YE. Medical image. A rare case of brachial artery fibromuscular dysplasia (FMD). N Z Med J 2011;124: 114-5.
