Role of mdc tin coronary artery part 5 (non atherosclerotic coronary abnormalities) dr ahmed esawy Role of mdc tin coronary artery part 4 (anomalous coronary arteries) dr ahmed esawy

1. Dr/AHMED ESAWY

2. Non-atherosclerotic
coronary abnormalities
• M. Kawasaki
• Myocardial bridging
• External compression
• Coronary dissection
• Coronary artery aneurysm ,ectasia
Dr/AHMED ESAWY

3. Kawasaki disease
Dr/AHMED ESAWY

4. Dr. Ahmed Esawy
MBBS M.Sc. MD
Dr/AHMED ESAWY

5. Coronary artery abnormalities in
Kawasaki disease
• acute, self-limiting vasculitis of
unknown etiology, mainly affects
younger children less than 4-5 years
old
• Coronary abnormalities
(aneurysm, stenosis, occlusion)
Dr/AHMED ESAWY

6. CT shows three aneurysms(yellow and red arrows) in proximal and middle
branches of RCA (a), correlated with conventional coronary angiography (c), however
MR missed the calified aneurysm in middle RCA (red arrow) (b). Moreover, middle RCA
was not seen on echocardiography (d).Dr/AHMED ESAWY

7. Both CT and MR shows multiple neurysms involving proximal and mid-portions
of RCA ("Beaded appearance"). Although calcifications are more visualized on CT, CT
overestimates the stenosis between aneruysms because of the calcifications
Dr/AHMED ESAWY

8. CORONARY ARTERY
ANEURYSMS
AND ECTASIA
Dr/AHMED ESAWY

9. Coronary artery aneurysms are defined as coronary
artery segments that
(a) Have a diameter that exceeds the diameter of normal
adjacent coronary segments or the diameter of the
patient’s largest coronary vessel by 1.5 times
And
(b) involve less than 50% of the total length of the vessel
Dr/AHMED ESAWY

10. right coronary artery (RCA) ectasia and a left circumflex artery aneurysm
Occlusion of the ectatic RCA with thrombus
(*). A fusiform aneurysm (arrow) is also
identified in the mid distal portion of the left
circumflex artery. Note the decreased
attenuation of its lumen, as compared with the
proximal segment, a finding that is due to the
slow flow within the aneurysm.
At coronary CT angiography, this finding might
be misinterpreted as occlusion when the flow
is extremely slow.
occluded RCA
RCA shows an absence of contrast
medium within the lumen
Dr/AHMED ESAWY

11. 65-year-old man. (a) Conventional coronary angiographic image shows a “saccular”
pouching (arrow) in the proximal portion of the left anterior descending coronary artery.
An aneurysm was diagnosed. (b) Curved planar reformatted image from coronary CT
angiography easily demonstrates that the conventional angiographic finding was a result
of ulceration of a large mixed plaque (arrow), and presence of an aneurysm was ruled
out. Unlike conventional angiography, one of the main advantages of coronary CT
angiography is the possibility of assessing the entire vessel wall.
Dr/AHMED ESAWY

12. Coronary artery aneurysm compared with coronary artery ectasia. (a, b) Drawing (a)
and coronal reformatted image (b) of a coronary artery aneurysm in a 55-yearold
man with stents in the left main and proximal circumflex coronary arteries. A saccular
atherosclerotic aneurysm (arrows) is seen in the mid distal portion of the left
ircumflex coronary artery. Lumen irregularities represent noncalcified atherosclerotic
plaque; stents are patent. n = normal.
Dr/AHMED ESAWY

13. Drawing (a) and volume-rendered image (b) of coronary artery ectasia in a 62-year-old man with
multiple cardiac risk factors. Ectasia is seen in the RCA, its posterolateral branch, and the left
anterior descending coronary artery (arrows). Note normal diameters (arrowheads) of the
coronaries; dilatation of the coronary arteries extends for more than 50% of the vessel length.
Most likely cause is atherosclerotic disease. n = normal.Dr/AHMED ESAWY

14. an atherosclerotic fusiform aneurysm (arrow) in a
65-year-old man. In this type of aneurysm, the length (L)
of the dilated portion of the coronary artery is
more than its transverse diameter (T).
Dr/AHMED ESAWY

15. saccular aneurysms, as the drawing (c) shows, the length (L) of the dilated portion is less
than its transverse diameter (T). This type of aneurysm is commonly seen as a poststenotic
dilatation, but in this 55-year-old man, the CT coronal multiplanar reconstruction of the left
main trunk (d) demonstrates a giant saccular atherosclerotic aneurysm (*) in the left main
trunk. Note the calcified (black arrow) and noncalcified (white arrow) plaques. Significant
coronary artery disease was noted in the midportion of the left anterior descending coronary
artery (not shown). Dr/AHMED ESAWY

16. Dr/AHMED ESAWY

17. Type I consists of diffuse dilatation of
two to three vessels, in this case the
RCA and the left anterior descending
coronary artery
Type III represents a solitary ectatic
vessel, in this case the RCA
Type IV is an aneurysm in one
vessel, again seen in the RCA.
Dr/AHMED ESAWY

18. Dr/AHMED ESAWY

19. atherosclerotic aneurysms.
(a) two fusiform aneurysms (arrows) in the proximal and middle portions of the left anterior
descending coronary artery. Note the irregularities within the lumen caused by calcified and
noncalcified plaques.
(b) the left circumflex coronary artery shows diffuse dilatation of almost the entire vessel (as
much as 7 mm in diameter and extending >50% of the length of the vessel). Atherosclerotic
plaques (arrows) are also seen as faint irregularities of the lumenDr/AHMED ESAWY

20. 19-year-old asymptomatic man
with a history of Kawasaki disease. (a) Axial
maximum intensity projection image shows
multiple fusiform aneurysms (as much as 12
mm in diameter) involving the left main
coronary artery and the proximal and middle
portions of the left anterior descending
coronary artery, resembling “tandem” lesions
(arrow).
multiple aneurysms (arrows)
found in this patient. Note that the images are
“noisy” because of the application of low kilo
voltage and dose modulation techniques.
Dr/AHMED ESAWY

21. 11-year-old boy with diagnosis of atrial septal defect
giant left main coronary artery (15 mm in diameter) that is due to a congenital fistula with
the right atrium. (a) Axial multiplanar reconstruction shows the important dilatation
(arrow) of the left main coronary artery. This vessel is equal in size to the aorta (Ao).
(b) Curved planar reformatted image demonstrates the entire course of the fistula
(arrows) Dr/AHMED ESAWY

22. a) Volume-rendered image shows ectasia (white arrows) of the RCA
and left anterior descending coronary artery (8 mm in diameter) caused by multiple
fistulas (black arrows) between these coronary arteries and the main pulmonary artery.
(b) Double oblique view shows one of the draining openings with its “jet” into the main
pulmonary artery (arrowhead).
Dr/AHMED ESAWY

23. (a) Axial coronary CT angiographic view clearly shows diffuse coronary
ectasia as a compensatory response that is due to an anomalous origin of the left
main coronary artery from the pulmonary artery (ALCAPA syndrome). Note the higher
attenuation within the pulmonary artery (PA) adjacent to the origin of the coronary
artery (arrow) because the flow direction is reversed (ie, from the coronary artery to
the pulmonary circulation). (b, c) Coronary CT angiographic four-chamber view (b)
and volume-rendered
Dr/AHMED ESAWY

24. image (c) demonstrate diffuse dilatation
of the RCA (black arrow), the mid distal portion of the left anterior descending
coronary artery, and the septal branches (white arrows).
Dr/AHMED ESAWY

25. Coronary CT angiographic images of a 42-year-old woman
with type I Takayasu arteritis and chest pain. Volume-
rendered (a, b) and axial (c) images show ectasia of the
RCA and its branches (arrowheads in a) as a compensatory
mechanism that is due to occlusion of the left main
coronary artery (arrow in b and c) secondary to coronary
artery vasculitis. The RCA gives collateral vessels to the left
coronary circulation, which are not frequently seen at CT
angiography, but in this case, a Vieussens collateral
pathway (arrowhead in b) is clearly shown.
This arch provides blood supply immediately distal to the
occlusion. The typical course of this collateral vessel is
anterior to the pulmonary artery Dr/AHMED ESAWY

26. Images of a 28-year-old woman with a saccular aneurysm of the RCA, possibly
secondary to Kawasaki disease, and acute chest pain
Dr/AHMED ESAWY

27. Coronary CT angiographic images obtained because of chest pain in a 58-year-old male heavy
smoker with a history of coronary artery disease. (a) Curved planar reformatted image of the
RCA demonstrates a saccular aneurysm (*) that is partially thrombosed, with leaking of the
contrast medium (arrow) into the mural thrombus within the aneurysm. The short-axis view
(inset) of the aneurysm also shows the leak (arrow). The patient was treated with a stent. (b)
Curved planar reformatted image and the short-axis view (inset) of the aneurysm (*) at follow-
up show adequate positioning of the stent (arrows) and no evidence of residual leaking. Curved
planar reformatted image of the left circumflex coronary artery of a 65-year-old man with
hypercholesterolemia, hypertension, and a history of atypical chest pain demonstrates a
saccular aneurysm with focal dissection secondary to coronary atherosclerosis An intimal flap
(arrow) projects into the lumen. Dr/AHMED ESAWY

28. CT image showing a large middle mediastinal mass with peripheral calcifications (M =
mass,
B, enhanced CT image showing a large inhomogeneous, enhancing (97 mm), middle
mediastinal mass with solid and cystic components compressing the right side of the
heart
Giant Right Coronary Artery Aneurysm Mimicking a Mediastinal Cyst With Compression Effects
Dr/AHMED ESAWY

29. CT angiography image showing a large aneurysm in the distal portion of the right
coronary artery. The proximal portion is intact
Dr/AHMED ESAWY

30. CORONARY ARTERY
DISSECTION
Dr/AHMED ESAWY

31. Schematic diagram of the mechanisms
of spontaneous coronary artery
dissection SCAD
Dr/AHMED ESAWY

32. Etiology of non-atherosclerotic SCAD
• Predisposing arteriopathy
Fibromuscular dysplasia
Pregnancy: history of multiple pregnancy, peri-partum
Connective tissue disorder: Marfan’s syndrome, Ehler
Danlos syndrome, cystic medial necrosis,
fibromuscular dysplasia
Systemic inflammation: systemic lupus erythematosus,
Crohn’s disease, polyarteritis nodosa, sarcoidosis
Hormonal therapy
Coronary artery spasm
Idiopathic
Dr/AHMED ESAWY

33. Etiology of non-atherosclerotic SCAD
• Precipitating stress events
Intense exercise (aerobic or isometric)
Intense emotional stress
Labor & delivery
Intense Valsalva-type activities (e.g., severe
repetitive coughing, retching/vomiting, bowel
movement)
Cocaine, amphetamines, met-amphetamines,
beta-HCG
Dr/AHMED ESAWY

34. Clinical features that raise suspicion of
SCAD
• Myocardial infarction in young women (especially age ≤50)
• Absence of traditional cardiovascular risk factors
• Little or no evidence of typical atherosclerotic lesions in coronary
arteries
• Peripartum state
• History of fibromuscular dysplasia
• History of relevant connective tissue disorder: Marfan’s syndrome,
Ehler Danlos syndrome, cystic medial necrosis, fibromuscular
dysplasia
• History of relevant systemic inflammation: systemic lupus
erythematosus, Crohn’s disease, ulcerative colitis, polyarteritis
nodosa, sarcoidosis
• Precipitating stress events, either emotional or physical (intensive
exercise)
Dr/AHMED ESAWY

35. Transaxial source image of a CCTA shows an
eccentric hypodense intramural hematoma
severely narrowing the crescent-shaped lumen
(white arrow) at the midportion of the LAD.
At a slightly more distal level, a curvilinear
intraluminal density representing an intimal
flap is noted (white arrow). There is
opacification of a smaller false lumen
The intimal flap terminates a few millimeters
more distally. Both true and false channels are
demonstrated (white arrow). There is
adequate opacification of the vessel distally
(not shown).
Spontaneous Coronary Artery Dissection
SCAD.
Dr/AHMED ESAWY

36. Curved multiplanar reformation nicely shows
the intramural hematoma (arrowhead) and
dissection flap, as seen in type E coronary
artery dissections (white arrow) . The vessel is
free of atherosclerosis
Using double oblique images of a multiplanar
reconstruction, a cross-sectional orthogonal
view of the LAD is obtained confirming the
presence of a dissecting flap and a false lumen
(white arrow).
Spontaneous Coronary Artery Dissection
SCAD.
Dr/AHMED ESAWY

37. Intracoronary ultrasound (IVUS) of the
corresponding LAD segment demonstrates a
false lumen (fl) occupied by an echogenic mass
(intramural hematoma). The true lumen (tl) is
compressed and narrowed (white arrows: flap,
c: catheter).
LAD cranial view demonstrates eccentric
narrowing (arrowhead) with differential
luminal opacification at its midportion (white
arrows). While there is no direct visualization
of the intramural hematoma or intimal flap,
these findings correlate well with the known
dissection per prior CCTA.
Spontaneous Coronary Artery Dissection
SCAD.
Dr/AHMED ESAWY

38. CORONARY
EXTERNAL COMPRESSION
Dr/AHMED ESAWY

39. Coronary computed tomography angiography.
(A) A maximum intensity projection image
shows a mild stenosis (shown by an arrow) at
the proximal left anterior descending
coronary artery.
(B) A long-axis view reveals a cardiac tumor
(shown by an arrow) surrounding the coronary
artery and invading the left ventricular anterior
wall.
Dr/AHMED ESAWY

40. Myocardial bridging in a coronary
artery segment. (a) Volume-
rendered image shows apparent
narrowing in a middle segment of
the left anterior descending
artery (arrow). (b, c) Conventional
angiograms show the typical
milking effect: The lumen of the
arterial segment (arrow) is
compressed by myocardial
contraction in the systolic phase
(b) but recovers its normal
diameter in the diastolic phase
(c). (d) Multiplanar reformatted image
provides excellent depiction of myocardial
bridging (arrow).Dr/AHMED ESAWY

41. Expanding pseudoaneurysm compressing the
coronary arteries and causing cardiogenic shock
compressing LAD by pseudoaneurysm
Dr/AHMED ESAWY

42. Coronary CT angiogram showing giant saphenous
venous graft aneurysm (a) compressing the
pulmonary artery (b).
Dr/AHMED ESAWY

43. Myocardial bridging
Myocardial bridging is a congenital coronary
anomaly involving its course, where's
a segment of epicardial coronary artery is either
partially or completely covered by surrounding
myocardium
Dr/AHMED ESAWY

44. Myocardial bridge at mid left anterior descending artery (LAD) visualized
with coronary computed tomographic angiography (CCTA). 2D curved multiplanar
reconstruction (a); Volume rendering (b).
Dr/AHMED ESAWY

45. Distal LAD myocardial bridge in a 74-year-old patient with angina and no
significant atherosclerotic stenosis on angiography. Volume rendering (left) shows a long
intramiocardial course as seen also in angiography (right). The distal LAD (circle) shows
a typical deviation and straitening and is only partially surrounded by myocardium
Dr/AHMED ESAWY

46. Distal LAD myocardial bridge visualized on multiplanar curve reformation in a
50 year old male with typical angina. In this case the tunneled myocardium is long and
superficial along the interventricular septum (circle).Dr/AHMED ESAWY

47. Mid LAD myocardial bridge in a 40 year old asymptomatic woman before valvular
replacement. CCTA multiplanar curve (left) and sagittal oblique (right) reformation shows
a very deep (4,5 mm) tunneled segment. There is an atherosclerotic plaque in the
proximal LAD, whereas the intramuscular segment is free of disease.
Dr/AHMED ESAWY

48. Myocardial bridging of a proximal left anterior descending coronary artery (LAD) segment
(arrows). Three-dimensional volume-rendered image (Panel A) and curved multiplanar
reformation (Panel B). Note the bridge of myocardial tissue overlying the LAD segment (arrows,
Panel B). D diagonal branch
Dr/AHMED ESAWY

49. Dr/AHMED ESAWY

50. Evaluation of LV function with MSCT. Short-axis view of end-diastolic phase (A) and
end-systolic phase (B). Akinesia and thinning of myocardium can be observed in the
inferolateral wall, due to previous myocardial infarction. Assessment of global LV
function revealed a severely reduced LVEF of 18% (LVEF: left ventricular ejection
fraction) (Quoted from de Graaf et al., 2010).
Evaluation of Left Ventricular Function
Dr/AHMED ESAWY