case report woven coronary artery disease successfully ...[ ]a.yldrm,d.o guz, and r. olguntrk, woven...

Case ReportWoven Coronary Artery Disease Successfully Managed withPercutaneous Coronary Intervention: A New Case Report

Yakup Alsancak,1 Burak Sezenoz,2 Sedat Turkoglu,3 and Adnan AbacJ3

1Department of Cardiology, Ataturk Education and Research Hospital, Bilkent, 06800 Ankara, Turkey2Department of Cardiology, Gazi Mustafa Kemal State Hospital, Gazi Mahallesi, 06500 Yenimahalle, Turkey3Department of Cardiology, Gazi University Medical Faculty, Besevler, 06500 Ankara, Turkey

Correspondence should be addressed to Burak Sezenoz; [email protected]

Received 22 July 2015; Accepted 15 September 2015

Academic Editor: Antonio de Padua Mansur

Copyright © 2015 Yakup Alsancak et al.This is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Woven coronary artery is relatively rare and can be complicated in both acute and chronic phases. A few case reports have beenpublished until now.Hereinwe report a casewith rightwoven coronary arterymanagedwith drug-eluted stent implantationwithoutcomplication.

1. Introduction

Woven coronary artery (WCA) disease is an extremely rarecongenital anomaly with unexplained etiology [1]. In thismalformation a part of epicardial coronary artery is dividedinto many long and thin channels. Thereafter these channelsmerge again in order to form the main coronary lumen aftertwisting along anomalous artery axis [2]. Previously pub-lished cases about this subject have shown that this anomalymay affect both right and left coronary artery (LAD). Normalblood flow after anomalous coronary segment secures relatedterritory; thus this condition is considered to be benign [3].Herein, we report a case of WCA in right coronary artery(RCA) successfully managed with percutaneous coronaryintervention (PCI) after abnormal myocardial perfusionscintigraphy.

2. Case Report

54-year-old male with tightening chest pain and palpitationon exertion for two months was admitted to cardiologyoutpatient clinic two years ago. Resting electrocardiogramshowed q waves and extra systoles on D3 and aVF. Echocar-diography showed akinesia at inferior and posterior walls,and ejection fraction was 44%. We performed coronaryangiography by using the Judkins technique from right

femoral artery. There were plaques at LAD and %50 stenosisat proximal Circumflex arteries, the lesions were consideredto be insignificant (Figure 1), and the patient had woven RCA(Figures 2 and 3). At nearly 5 cm middle portion of RCA,numerous small tortious channels formed the lumen and theywere merged again after the anomalous segment (Figure 4).There was TIMI III flow at the distal part of the anomaloussegment. No other lesion was found to explain the patient’scomplaints; therefore thallium-myocardial perfusion scintig-raphy was performed in order to assess ischemic burden ofRCA territory. Inferior wall ischemia was detected whichapproximately refers to %14 of left ventricle. Optimal anti-ischemic treatment did not relieve anginal symptoms andnonsustained ventricular tachycardia episodes were detectedin Holter ECG recording that led us to PCI to anomalousRCA portion. Woven pattern was confirmed at RCA withno apparent coronary stenosis. 6F guiding catheter wasplaced to RCA ostium and then 0.014 floppy guiding wirewas forwarded to anomalous portion (Figure 5). 1.5/15mmchronic total occlusion angioplasty balloon was used to reachlesion. Control imaging showed protected TIMI III flowin RCA. After dilatation, two 2.5/28mm everolimus-elutedstents were implanted to the anomalous portion after balloondilatation (Figures 6 and 7). TIMI III flow was ensured afterstent implantation.

Hindawi Publishing CorporationCase Reports in CardiologyVolume 2015, Article ID 516539, 3 pageshttp://dx.doi.org/10.1155/2015/516539

2 Case Reports in Cardiology

Figure 1: Plaques at left anterior descending artery and borderlinelesion ostial Circumflex artery.

Figure 2:Woven coronary artery anomaly at themidsegment of theright coronary artery.

Figure 3: There is normal blood flow at the distal RCA segment ofthe anomaly.

3. Discussion

Woven coronary artery (WCA) is a very rare congenitalanomaly which can affect both RCA and LAD and may leadto acute coronary syndromes in some circumstances [4]. Itwas first described twenty-five years ago and only a few caseshave been reported [2]. There is a male predominancy andonly one case of a child has been reported. The distanceof abnormal part is limited a few centimeters and bloodflow is similar before to the diseased area [3]. Yldrm andhis colleagues were speculating that this pathology may becaused by recanalisation of a thrombus [4]. The differentialdiagnosis should include recanalized thrombus, spontaneouscoronary artery dissection, and bridging collaterals [3, 4].

Figure 4: Coronary angiography showed proximal thin channelsand distal reanastomosis.

Figure 5: Right coronary artery and TIMI III flow after floppyguidewires.

Figure 6: Right coronary artery and WCA after first distal stentimplantation.

Figure 7: RCA after percutaneous coronary intervention and distalnormal blood flow.

Case Reports in Cardiology 3

This anomaly may be accepted as a benign disease. Somereports showed no cardiovascular adverse events during 5-year follow-up [3–5]. Nevertheless some authors stated thatthis anomaly can be associated withmyocardial ischemia anddamage in their cases [6, 7]. In our case, the optimal medicaltreatment was started after the first coronary angiographybut the chest pain persisted. Because of refractory anginaand inferior wall ischemia in myocardial perfusion imaging,PCI was performed to the WCA segment of right coronaryartery. Before this report, an inferior myocardial infarctiondue toWCAdiseasewas reported, but PCIwas not performedbecause the coronary artery was affected extensively [7].Intravascular ultrasound (IVUS) can be a useful technique inorder to manage stent position and to verify adequate stentexpansion in these types of patients. Moreover in a patientwith multiple vessel disease who underwent bypass surgeryand the other who underwent aortic valve operation withwoven anomaly has not been revascularized [3, 8]. To ourknowledge, only one case has been reported about successfulPCI for WCA [9].

4. Conclusion

In conclusion, WCA may cause myocardial ischemia anddamage. All interventional cardiologists might keep thisanomaly in mind and should beware of the possible con-sequences of WCA in catheterisation laboratory. PCI orcoronary artery bypass grafting may be treatment options forthis anomaly.

Conflict of Interests

The authors state that they have no conflict of interests.

References

[1] L. Gregorini, R. Perondi, G. Pomidossi, A. Saino, I. M. Bossi,and A. Zanchetti, “Woven left coronary artery disease,” TheAmerican Journal of Cardiology, vol. 75, no. 4, pp. 311–312, 1995.

[2] D. C. Sane andH. J. Vidaillet Jr., “‘Woven’ right coronary artery:a previously undescribed congenital anomaly,” The AmericanJournal of Cardiology, vol. 61, no. 13, article 1158, 1988.

[3] H. Kursaklioglu, A. Iyisoy, and T. Celik, “Woven coronaryartery: a case report and review of literature,” InternationalJournal of Cardiology, vol. 113, no. 1, pp. 121–123, 2006.

[4] A. Yldrm, D. Oǧuz, and R. Olguntrk, “Woven right andaneurysmatic left coronary artery associated with Kawasakidisease in a 9-month-old patient,” Cardiology in the Young, vol.20, no. 3, pp. 342–344, 2010.

[5] E. Martuscelli, F. Romeo, M. Giovannini, and A. Nigri, “Wovencoronary artery: differential diagnosis with diffuse intracoro-nary thrombosis,” Italian Heart Journal, vol. 1, no. 4, pp. 306–307, 2000.

[6] A. Bozkurt, O. Akkus, S. Demir, O. Kaypakli, and M. Demirtas,“A new diagnostic method for woven coronary artery: opticalcoherence tomography,” Herz, vol. 38, no. 4, pp. 435–438, 2013.

[7] K. Soylu, M. Meric, H. Zengin, S. Yüksel, and M. G. Kaya,“Woven right coronary artery,” Journal of Cardiac Surgery, vol.27, no. 3, pp. 345–346, 2012.

[8] D. Kaya, C. Kilit, and E. Onrat, “An uncommon congenitalanomaly of coronary arteries misdiagnosed as intracoronarythrombus:Woven coronary artery disease,”Anadolu KardiyolojiDergisi, vol. 6, no. 4, pp. 383–384, 2006.

[9] A. Tasal, A. Bacaksiz, E. Erdogan, and Z. Küçükdurmaz, “Suc-cessful percutaneous management of occluded ‘woven’ coro-nary artery: a case report,” Postepy w Kardiologii Interwencyjnej,vol. 8, no. 2, pp. 168–172, 2012.

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