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Patient initials or identifier number
Relevant clinical history and physical exam
A 58 year-old women was admitted with worsening chest pain on exertion. Her coronary risk factors were hypertension, dyslipidemia, and family history. She doesn’t have any allergies. Her body type was almost normal(height 150 cm, body weight 51 kg, BMI 22.7 kg/m2), and her vital signs showed hypertension (pulse 72 bpm, blood pressure: 173/103 mmHg, SpO2 97% (room air),Body temperature 35.8°C). She doesn’t have any abnormal physical examination findings.
Relevant test results prior to catheterization
Coronary computed tomographic angiography (CCTA)revealed that the proximal right coronary artery (RCA) had a severe stenosis with excessive positive remodeling. We performed primary percutaneous coronary intervention (PCI) and platinum chromium everolimus-eluting stent (PtCr-EES)was deployed in RCA.
Relevant catheterization findings
At 8 months after first PCI, she had recurrence of chest pain and the coronary angiography (CAG) showed an in stent occlusive lesion of RCA and new 75% stenosis in proximal of both left anterior descending artery (LAD) and left circumflex artery (LCX). RCA was treated with paclitaxel coated balloon (PCB), and other lesions were followed up with medical therapy because a stress myocardial perfusion scintigraphy demonstrated just mild ischemia.
After 6 months the second PCI, follow up CAG showed progression of LAD and LCX stenosis and recurrent in stent restenosis (ISR) of PtCr-EES which had been implanted in RCA 14 months ago. By CAG, the lesional morphology of LAD was unclear due to many micro vessels around the main vessel. CCTA revealed massive periarterial soft tissue, which looked like “tumor”, in the proximal part of LAD and LCX. We informed about therapeutic options for these recurrent restenosis and rapid progressive coronary artery disease and she gave her consent to be underwent PCI. PCI was performed both with optical coherence tomography (OCT) and intravascular ultrasound (IVUS). OCT showed lotus root appearance, and IVUS showed heavily thickened adventitia at the LAD. Finally, successful recanalization of left main bifurcation lesion was achieved by culotte stenting using zotarolimus-eluting stents (ZES). And RCA lesion was treated with PCB again at the same PCI session. Unfortunately, 5 months later,on the follow up CAG showed an ISR at LAD ZES, and then, she was finally performed coronary artery bypass grafting.
The findings of the coronary imaging modality, such as tumor like finding with CCTA and thickened adventitia with IVUS, suggested coronary periarteritis. Coronary periarteritis might be caused rapid progression of coronary stenosis, recurrence of ISR and thrombotic coronary occlusion.