Mass General Hospital
June 2008
ISSUE 9
 
 
48 Year-Old Woman with a Left Main Coronary Artery (LMCA) Stent and Much More...
Leon Shturman, MD, Amar Shah, MD, Jeffrey Jednacz, MD, Ignacio Inglessis, MD, Suhny Abbara, MD, and Wilfred Mamuya, MD, PhD

  
  Clinical History
A 48 year-old woman, status-post failed patent ductus arteriosus (PDA) surgical closure complicated by Eisenmenger syndrome with severe pulmonary hypertension, underwent left main (LM) artery stenting secondary to focal extrinsic ostial left main coronary artery (LMCA) compression by a markedly dilated pulmonary artery (Fig. 1, arrow). She was referred for a dual source coronary CT angiogram (DSCT) evaluation of LMCA stent patency, in-lieu of traditional coronary angiography.

Findings
A LMCA stent measuring 5x16 mm was found to be widely patent with protrusion of its proximal portion into the aortic lumen (Fig. 2, arrow). In addition, DSCT demonstrated a markedly dilated pulmonary arterial (PA) system. The right pulmonary artery was noted to have an organized mural thrombus (Fig. 3, arrows). The PDA was demonstrated in the proximal segment of the descending aorta measuring 1.7 cm in the greatest diameter (Fig. 4, asterisk).

Figure 1. Maximum intensity projection (MIP) demonstrating compression of the ostium of left main (arrow) coronary artery by a markedly enlarged main pulmonary artery (MPA)
Figure 1.
 Figure 2. MIP showing relief of LM compression with a patent stent protruding into the aorta (Ao)
Figure 2.
Figure 3. MIP showing markedly enlarged main pulmonary artery (MPA), left pulmonary artery (LPA), and right pulmonary artery (RPA) with mural thrombus
Figure 3.
Figure 4. MIP demonstrating a patent ductus (*) connecting the aorta to an enlarged left pulmonary artery (LPA)
Figure 4.
(Click on images to enlarge)

Figure 1. Maximum intensity projection (MIP) demonstrating compression of the ostium of left main (arrow) coronary artery by a markedly enlarged main pulmonary artery (MPA)

Figure 2. MIP showing relief of LM compression with a patent stent protruding into the aorta (Ao)

Figure 3. MIP showing markedly enlarged main pulmonary artery (MPA), left pulmonary artery (LPA), and right pulmonary artery (RPA) with mural thrombus

Figure 4. MIP demonstrating a patent ductus (*) connecting the aorta to an enlarged left pulmonary artery (LPA)

Discussion
LMCA stenting is emerging as a viable alternative to coronary artery bypass surgery in a few carefully selected patients. A post-surveillance coronary angiogram in 3-6 months is currently considered part of the standard of care. DSCT represents a valuable non-invasive imaging tool capable of providing this type of surveillance. Furthermore, this case illustrates the additional capability of DSCT in elucidating other important and clinically relevant findings in a single examination.


  
 
REFERENCES
1. Van Mieghem et al, Multislice Spiral Computed Tomography for the Evaluation of Stent Patency After Left main Coronary Artery Stenting. Circulation 2006;111:645-653.
2. El-Menyar et al, Left Main Coronary Artery Stenosis: State-of-the-Art. Current Problems in Cardiology 2007;32:103-193.
   

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Editors:
Suhny Abbara, M.D.
MGH Department of Radiology
Wilfred Mamuya, M.D., Ph.D.
MGH Division of Cardiology

Phone: 617-726-5954