左主干血管痉挛伪装成严重狭窄导致不必要的手术

Q4 Medicine

JACC. Case reports Pub Date : 2025-09-24 DOI:10.1016/j.jaccas.2025.105231

Francesca Di Lenarda MD , Riccardo Terzi MD, BSc , Michele Gallazzi MD , Giovanni Monizzi MD , Emanuele Gallinoro MD, PhD , Pasquale Paolisso MD, PhD , Davide Marchetti MD , Edoardo Conte MD, PhD , Antonio L. Bartorelli MD , Daniele Andreini MD, PhD

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引用次数: 0

摘要

背景：血管痉挛性心绞痛是一种由心外膜冠状动脉痉挛确定的疾病，通常由静息性心绞痛诊断。病例总结：一名62岁男性患者因复发性静息性心绞痛入院，此前曾行冠状动脉旁路移植术和单纯的旧球囊血管成形术治疗多支血管疾病。冠状动脉计算机断层血管造影显示闭塞的搭桥血管，但不明显的冠状动脉粥样硬化，以及弥漫性冠状动脉扩张和心肌桥。在有创性重新评估时，血管内超声证实阳性重塑和内膜增厚，提示血管痉挛病理。血管造影时严重的局灶性心外膜血管痉挛触发心室颤动，经除颤逆转。一过性右冠状动脉闭塞伴st段抬高，硝酸解决，突出血管痉挛的动态性质。本病例强调了考虑冠状血管痉挛对血管造影结果不明确患者的重要性，冠状动脉内硝酸甘油的诊断和治疗作用，以及成像在避免不必要的血运重建中的价值。仔细的药理学检查和生理学评估是区分功能性血管痉挛和固定冠状动脉疾病的必要条件，特别是在左主干受累时。

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Left Main Vasospasm Masquerading as Critical Stenosis Leading to Unnecessary Surgery

Background

Vasospastic angina is a condition determined by epicardial coronary artery spasm, which is usually diagnosed from resting angina.

Case Summary

A 62-year-old man was admitted for recurrent rest angina despite previous coronary artery bypass grafting and plain-old balloon angioplasty for multivessel disease. Coronary computed tomography angiography revealed occluded bypass grafts but nonsignificant coronary atherosclerosis, along with diffuse coronary ectasia and myocardial bridging. During invasive re-evaluation, intravascular ultrasound confirmed positive remodeling and intimal thickening, suggestive of vasospastic pathology. Critical, focal epicardial vasospasm during angiography triggered ventricular fibrillation, reversed by defibrillation. A transient right coronary artery occlusion with ST-elevation resolved with nitrates, highlighting the dynamic nature of the vasospasm.

Discussion

The case emphasizes the importance of considering coronary vasospasm in patients with ambiguous angiographic findings, the diagnostic and therapeutic role of intracoronary nitroglycerin, and the value of imaging in avoiding unnecessary revascularization. Careful pharmacologic testing and physiologic assessment are essential to distinguish functional vasospasm from fixed coronary disease, especially in left main involvement.

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