Case report
Diffuse aneurysmal and obstructive coronary artery disease: A do-not-intervene patient
Doença coronária aneurismática e obstrutiva difusa: um doente a não intervir
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Akkus, Jagan Beedupalli, Jai Varma" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nuri I." "apellidos" => "Akkus" ] 1 => array:2 [ "nombre" => "Jagan" "apellidos" => "Beedupalli" ] 2 => array:2 [ "nombre" => "Jai" "apellidos" => "Varma" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113001248?idApp=UINPBA00004E" "url" => "/08702551/0000003200000078/v1_201308220036/S0870255113001248/v1_201308220036/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Diffuse aneurysmal and obstructive coronary artery disease: A do-not-intervene patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "629" "paginaFinal" => "632" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Eulália Pereira, Bruno Melica, João Primo, João C. Mota, Nuno Ferreira, Gustavo P. Morais, Marta Ponte, Daniel Caeiro, Mónica Carvalho, Nuno Bettencourt, Luís Vouga, Vasco Gama" "autores" => array:12 [ 0 => array:4 [ "nombre" => "Eulália" "apellidos" => "Pereira" "email" => array:1 [ 0 => "eulaliaalvespereira@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Bruno" "apellidos" => "Melica" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "João" "apellidos" => "Primo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "João C." 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Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Marta" "apellidos" => "Ponte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Daniel" "apellidos" => "Caeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Mónica" "apellidos" => "Carvalho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "Luís" "apellidos" => "Vouga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 11 => array:3 [ "nombre" => "Vasco" "apellidos" => "Gama" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Cardiothoracic Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença coronária aneurismática e obstrutiva difusa: um doente a não intervir" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3478 "Ancho" => 2333 "Tamanyo" => 734129 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abnormal coronary artery appearance in different techniques. A large aneurysm (arrowheads) is seen at the distal edge of the left main trunk (A1, B1, C1 and C2). The left anterior descending artery (LAD) presents several aneurysms (arrows) but also severe stenotic lesions (resembling a string of beads) with a poor distal bed (A1, B1 and C1). Note the absence of circumflex artery visualization. The ectatic right coronary artery (RCA) also presenting aneurysmal formations (arrows) and obstructive lesions (A2, B2 and C2). A: coronary angiograms of the LAD and RCA. B: curved planar reformation (CPR) in multislice computed tomography (MSCT) of the LAD and RCA. C: Three-dimensional MSCT reconstructions (volume-rendering technique). *: ascending aorta.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery aneurysms (CAA) are uncommon entities found on a small percentage of coronary angiograms (0.3%–4.9%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They may be single or multiple, associated with stenotic coronary disease or not, symptomatic or asymptomatic, and may lead to serious complications. The best management strategy for coronary artery aneurysms has not been established and prognosis appears to be directly related to the severity of the concomitant obstructive coronary artery disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this case report is to highlight the clinical presentation, work-up and treatment options for a patient with mixed aneurysmal and stenotic coronary artery disease involving all three major coronary arteries.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 52-year-old Caucasian woman with a history of hypertension and glaucoma presented at our emergency department with persistent chest pain for a few hours. The pain occurred during rest, radiated to the left arm and was accompanied by profuse sweating. The patient had no personal or family history of injury, connective tissue disease, or rheumatic fever. The physical examination was unexceptional.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory exams performed on admission to the hospital showed no abnormalities.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A 12-lead electrocardiogram (ECG) showed sinus rhythm, heart rate 43 bpm, poor progression of R wave in the precordial leads, ST depression in leads V3 to V6 and inverted T waves in leads V1 to V4.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Troponin I levels were initially negative, but rose during the course of the patient's hospitalization, reaching a maximum of 23.76 ng/ml.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was admitted to intensive care and was started on aspirin, clopidogrel, unfractionated heparin and a statin. Soon after admission, electrical instability developed (ectopic ventricular beats with R on T phenomena and nonsustained ventricular tachycardia episodes) and urgent coronary catheterization was performed.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Coronary angiograms revealed a large aneurysm involving the origin of the circumflex artery, with a maximum diameter of 16<span class="elsevierStyleHsp" style=""></span>mm, and irregular enhancement in the periphery with thrombus (Video 1 and <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A1). The distal bed of the circumflex artery was very poorly perfused by collaterals of the right coronary artery. The left anterior descending artery also showed multiple saccular aneurysms and multilevel stenosis up to 70% with poor distal run-off (Videos 1 and 2 and <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A1). The right coronary artery presented mild diffuse ectasia, multiple aneurysms and significant stenosis in the mid and distal portions (Video 3 and <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A2). An aortogram with runoff showed a normal thoracic aorta.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Multislice computed tomography (MSCT) confirmed the appearance of the coronary arteries resembling a string of beads due to the presence of multiple aneurysms interspersed with critical stenotic lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B and C). No other cardiac abnormalities were detected.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A two-dimensional echocardiogram revealed ejection fraction of 45% with lateral and posterior hypokinesis, left atrial enlargement (area 21<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>) and minor valvular abnormalities.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Renal and liver function tests were normal, and those for other inflammatory markers, rheumatoid factor, venereal disease, cryoglobulin, complement activity, antiphospholipid antibodies, antinuclear antibodies, extractable nuclear antigens, and antineutrophil cytoplasmic antibodies were negative, as were tests for hepatitis B and C and human immunodeficiency virus. Coagulation inhibitor system function was normal.</p><p id="par0060" class="elsevierStylePara elsevierViewall">MSCT of our patient indicated no other malformation of arteries in the head, trunk, or extremities.</p><p id="par0065" class="elsevierStylePara elsevierViewall">After consultation with a multidisciplinary team that included a cardiothoracic surgeon, an interventional cardiologist and the attending cardiologist, any interventional treatment for our patient was deemed too high-risk. A surgical approach was hampered by the severity of obstructive coronary disease and the absence of suitable vessels for bypass. Likewise, the multiplicity and complexity of the stenotic and aneurysmal lesions ruled out any percutaneous stenting or embolization. A conservative approach was unanimously decided upon, including maximization of antithrombotic therapy (double antiplatelet therapy and a vitamin K inhibitor) and anti-ischemic therapy (statin, ACE inhibitor, beta-blocker and nitrates).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The patient had an uneventful hospitalization and was discharged home on the fifth day. At the 12-month follow-up she was still asymptomatic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The first pathologic description of a CAA was by Morgagni in 1761.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It was first diagnosed by angiography by Munker and colleagues in 1958.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> CAA is defined as a segmental dilatation of the vessel, with a diameter ≥1.5 times (according to some authors, ≥2 times) that of an adjacent normal section. Ectasia is characterized by a more diffuse dilatation involving at least 50% of the vessel length. Coronary ectasia and aneurysm are thought to represent subsequent stages of a dilatative process. The right coronary artery is most frequently involved (40%–61%), followed by the left anterior descending coronary artery (15%–32%) and the left circumflex artery (15%–23%). Three-vessel or left main involvement is rare.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Almost half of cases of CAA occur as a consequence of atherosclerosis. The next most common cause is congenital (20%–30%). Other causes include vasculitis (such as Kawasaki disease, Takayasu's arteritis and polyarteritis nodosa), systemic lupus erythematosus, connective tissue disorders, Ehlers–Danlos syndrome, Marfan syndrome, infections (such as narcotic emboli, syphilis and Lyme disease), trauma, cocaine abuse, as a complication of percutaneous transluminal coronary angioplasty, and of idiopathic origin.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The exact pathogenic mechanism is unknown; possible contributory factors include genetic predisposition, traditional risk factors for coronary artery disease, direct arterial wall damage and abnormal vessel wall metabolism.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The simultaneous presence of CAA and coronary artery disease in our patient, along with the presence of multiple aneurysms and involvement of more than one coronary artery, indicate atherosclerosis as the main cause. By contrast, congenital, traumatic, or dissecting aneurysms are mainly single.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The clinical presentation of CAA is varied. Atherosclerotic aneurysms usually present with ischemic symptoms such as angina and myocardial infarction. They also portend life-threatening complications such as rupture, vasospasm, thromboembolism, compression of surrounding structures and, more rarely, fistulization into one of the cardiac chambers.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These cases may present in extremis with tamponade, heart failure or even sudden death.</p><p id="par0100" class="elsevierStylePara elsevierViewall">CAA are commonly associated with aneurysms of other locations, particularly aortic and iliofemoral.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Coronary angiography is the gold standard in the diagnosis of CAA. MSCT is an excellent alternative diagnostic method, especially in determining the exact anatomy and its relation to adjacent structures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The best management strategy for CAA has not been defined. Medical, interventional and surgical strategies have been described, but an individualized approach is recommended according to the location of the aneurysm and the clinical context.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Conservative therapy includes antiplatelet and anticoagulant agents to prevent thrombus formation in the aneurysm and distal embolization.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Surgical treatment is preferred for symptomatic patients who have evidence of embolization from the aneurysm to the distal coronary bed and those with large aneurysms, to avoid potential complications. Surgery is also indicated in cases of CAA enlargement in serial angiographic measurements.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Various surgical techniques can be applied, such as isolating or resecting the aneurysm and reconstructing the coronary course using an interposition graft, or maintaining distal coronary flow via concomitant coronary artery bypass grafting.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Because of the severe atherosclerosis and absence of suitable arteries for bypass grafting, our patient was not considered a good surgical candidate.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Percutaneous treatment is a newer option and includes coil embolization and stenting. According to Szalat et al.,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> polytetrafluoroethylene-covered stents appear to be of value in patients with aneurysms smaller than 10<span class="elsevierStyleHsp" style=""></span>mm in diameter as no cases of in-stent restenosis were reported in this group. Alternatively, drug-eluting stents reduce risk of in-stent restenosis; however, malapposition of such stents in aneurysmal segments increases risk of stent thrombosis, and may contribute to further aneurysm formation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The prognosis of CAA is directly related to the severity of the concomitant obstructive coronary artery disease. According to the Coronary Artery Surgery Study registry,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> there was no difference in five-year survival between patients with and without aneurysms who had obstructive coronary artery disease.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our patient has remained asymptomatic with medical treatment alone, under close surveillance every three months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">We report the case of a middle-aged woman who presented with an acute myocardial infarction and had mixed aneurysmal and obstructive coronary artery disease. Several cases of coronary artery aneurysms have been published. Our case is unusually complex, with all three major coronary arteries involved by diffuse atherosclerotic disease presenting simultaneously in different forms: multiple aneurysms of varying sizes interspersed with critical stenotic lesions all along the coronary beds. The presence of coronary aneurysms per se is not an indication for surgical treatment. Rather, the severity of coexisting obstructive coronary artery disease is the principal factor in deciding whether to proceed with surgery in patients with CAA. However, surgical management of our patient was ruled out by the poor distal vessel runoff and a percutaneous approach was also considered impracticable.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres257769" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec245353" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres257770" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec245352" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-02" "fechaAceptado" => "2012-11-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec245353" "palabras" => array:3 [ 0 => "Coronary artery aneurysms" 1 => "Atherosclerosis" 2 => "Acute myocardial infarction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec245352" "palabras" => array:3 [ 0 => "Aneurismas coronários" 1 => "Aterosclerose" 2 => "Enfarte agudo do miocárdio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary artery aneurysms are uncommon but potentially hazardous entities found on a small percentage of coronary angiograms. The best management strategy remains to be determined; the coexistence of obstructive coronary artery disease is the main determinant of prognosis.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a middle-aged woman with mixed aneurysmal and obstructive coronary artery disease presenting as an acute myocardial infarction, probably due to atherosclerosis. The unusual severity and complexity of the angiographic presentation of this case, with involvement of all major coronary arteries, raises important issues in terms of the patient's treatment options.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Os aneurismas das artérias coronárias são entidades raras, presentes numa pequena percentagem das angiografias coronárias, embora associadas a complicações potencialmente graves. A melhor conduta no tratamento destas situações ainda não foi estabelecida e a coexistência de doença coronária obstrutiva é o principal determinante prognóstico.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reportamos o caso de uma mulher de meia-idade com doença coronária mista, obstrutiva e aneurismática, diagnosticada no contexto de enfarte agudo do miocárdio e de provável etiologia aterosclerótica. A gravidade e a complexidade incomuns da apresentação angiográfica do nosso caso, levantaram aos autores questões importantes no domínio da decisão terapêutica.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3478 "Ancho" => 2333 "Tamanyo" => 734129 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abnormal coronary artery appearance in different techniques. A large aneurysm (arrowheads) is seen at the distal edge of the left main trunk (A1, B1, C1 and C2). The left anterior descending artery (LAD) presents several aneurysms (arrows) but also severe stenotic lesions (resembling a string of beads) with a poor distal bed (A1, B1 and C1). Note the absence of circumflex artery visualization. The ectatic right coronary artery (RCA) also presenting aneurysmal formations (arrows) and obstructive lesions (A2, B2 and C2). A: coronary angiograms of the LAD and RCA. B: curved planar reformation (CPR) in multislice computed tomography (MSCT) of the LAD and RCA. C: Three-dimensional MSCT reconstructions (volume-rendering technique). *: ascending aorta.</p>" ] ] 1 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Video 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 13923 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography of left coronary artery (cranial projection). At the distal edge of the left main trunk, a large coronary aneurysm arises with irregular enhancement in the periphery. The circumflex artery is not seen. The left anterior descending artery shows multiple saccular aneurysms alternating with significant obstructive lesions resembling a string of beads. The distal run-off is poor.</p>" ] ] 2 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Video 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 19641 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography of left coronary artery (lateral projection). The circumflex artery is occluded at the origin by a large aneurysm. Also note the very poor distal bed of the left anterior descending artery and the image suggestive of thrombus inside the large aneurysm.</p>" ] ] 3 => array:7 [ "identificador" => "upi0015" "etiqueta" => "Video 3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 12464 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography of the right coronary artery. The right coronary artery is diffusely ectatic and also has several aneurysms. The mid and distal portions of the vessel show significant stenotic lesions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary ectasia: its prevalence and clinical significance in 4993 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.G. Hartnell" 1 => "B.M. Parnell" 2 => "R.B. 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| Ano/Mês | Html | Total | |
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| 2024 Fevereiro | 44 | 46 | 90 |
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| 2023 Novembro | 46 | 36 | 82 |
| 2023 Outubro | 40 | 25 | 65 |
| 2023 Setembro | 39 | 20 | 59 |
| 2023 Agosto | 44 | 21 | 65 |
| 2023 Julho | 23 | 16 | 39 |
| 2023 Junho | 32 | 8 | 40 |
| 2023 Maio | 38 | 26 | 64 |
| 2023 Abril | 29 | 9 | 38 |
| 2023 Maro | 41 | 20 | 61 |
| 2023 Fevereiro | 47 | 19 | 66 |
| 2023 Janeiro | 29 | 14 | 43 |
| 2022 Dezembro | 36 | 21 | 57 |
| 2022 Novembro | 55 | 31 | 86 |
| 2022 Outubro | 28 | 22 | 50 |
| 2022 Setembro | 39 | 41 | 80 |
| 2022 Agosto | 46 | 25 | 71 |
| 2022 Julho | 47 | 39 | 86 |
| 2022 Junho | 29 | 28 | 57 |
| 2022 Maio | 38 | 36 | 74 |
| 2022 Abril | 37 | 27 | 64 |
| 2022 Maro | 39 | 41 | 80 |
| 2022 Fevereiro | 35 | 19 | 54 |
| 2022 Janeiro | 40 | 21 | 61 |
| 2021 Dezembro | 38 | 33 | 71 |
| 2021 Novembro | 41 | 42 | 83 |
| 2021 Outubro | 35 | 46 | 81 |
| 2021 Setembro | 30 | 32 | 62 |
| 2021 Agosto | 36 | 28 | 64 |
| 2021 Julho | 27 | 22 | 49 |
| 2021 Junho | 18 | 22 | 40 |
| 2021 Maio | 25 | 35 | 60 |
| 2021 Abril | 35 | 20 | 55 |
| 2021 Maro | 69 | 15 | 84 |
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| 2021 Janeiro | 34 | 13 | 47 |
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| 2020 Novembro | 30 | 9 | 39 |
| 2020 Outubro | 20 | 20 | 40 |
| 2020 Setembro | 53 | 7 | 60 |
| 2020 Agosto | 28 | 10 | 38 |
| 2020 Julho | 32 | 11 | 43 |
| 2020 Junho | 35 | 6 | 41 |
| 2020 Maio | 34 | 3 | 37 |
| 2020 Abril | 27 | 9 | 36 |
| 2020 Maro | 43 | 12 | 55 |
| 2020 Fevereiro | 62 | 27 | 89 |
| 2020 Janeiro | 34 | 12 | 46 |
| 2019 Dezembro | 40 | 24 | 64 |
| 2019 Novembro | 30 | 9 | 39 |
| 2019 Outubro | 38 | 5 | 43 |
| 2019 Setembro | 30 | 8 | 38 |
| 2019 Agosto | 28 | 5 | 33 |
| 2019 Julho | 34 | 23 | 57 |
| 2019 Junho | 27 | 11 | 38 |
| 2019 Maio | 46 | 19 | 65 |
| 2019 Abril | 22 | 17 | 39 |
| 2019 Maro | 29 | 24 | 53 |
| 2019 Fevereiro | 53 | 17 | 70 |
| 2019 Janeiro | 27 | 7 | 34 |
| 2018 Dezembro | 40 | 19 | 59 |
| 2018 Novembro | 85 | 8 | 93 |
| 2018 Outubro | 187 | 23 | 210 |
| 2018 Setembro | 47 | 10 | 57 |
| 2018 Agosto | 53 | 15 | 68 |
| 2018 Julho | 30 | 13 | 43 |
| 2018 Junho | 51 | 9 | 60 |
| 2018 Maio | 52 | 12 | 64 |
| 2018 Abril | 67 | 8 | 75 |
| 2018 Maro | 99 | 6 | 105 |
| 2018 Fevereiro | 54 | 8 | 62 |
| 2018 Janeiro | 19 | 9 | 28 |
| 2017 Dezembro | 101 | 10 | 111 |
| 2017 Novembro | 37 | 11 | 48 |
| 2017 Outubro | 27 | 8 | 35 |
| 2017 Setembro | 40 | 8 | 48 |
| 2017 Agosto | 58 | 7 | 65 |
| 2017 Julho | 36 | 9 | 45 |
| 2017 Junho | 47 | 24 | 71 |
| 2017 Maio | 39 | 17 | 56 |
| 2017 Abril | 24 | 6 | 30 |
| 2017 Maro | 50 | 20 | 70 |
| 2017 Fevereiro | 27 | 11 | 38 |
| 2017 Janeiro | 22 | 8 | 30 |
| 2016 Dezembro | 23 | 10 | 33 |
| 2016 Novembro | 26 | 16 | 42 |
| 2016 Outubro | 81 | 14 | 95 |
| 2016 Setembro | 98 | 8 | 106 |
| 2016 Agosto | 13 | 7 | 20 |
| 2016 Julho | 6 | 10 | 16 |
| 2016 Junho | 3 | 16 | 19 |
| 2016 Maio | 29 | 0 | 29 |
| 2016 Abril | 55 | 3 | 58 |
| 2016 Maro | 109 | 12 | 121 |
| 2016 Fevereiro | 102 | 18 | 120 |
| 2016 Janeiro | 100 | 13 | 113 |
| 2015 Dezembro | 99 | 10 | 109 |
| 2015 Novembro | 97 | 13 | 110 |
| 2015 Outubro | 107 | 16 | 123 |
| 2015 Setembro | 120 | 12 | 132 |
| 2015 Agosto | 102 | 13 | 115 |
| 2015 Julho | 137 | 8 | 145 |
| 2015 Junho | 62 | 2 | 64 |
| 2015 Maio | 73 | 7 | 80 |
| 2015 Abril | 81 | 9 | 90 |
| 2015 Maro | 48 | 8 | 56 |
| 2015 Fevereiro | 81 | 7 | 88 |
| 2015 Janeiro | 62 | 6 | 68 |
| 2014 Dezembro | 84 | 8 | 92 |
| 2014 Novembro | 67 | 10 | 77 |
| 2014 Outubro | 81 | 11 | 92 |
| 2014 Setembro | 65 | 5 | 70 |
| 2014 Agosto | 76 | 9 | 85 |
| 2014 Julho | 95 | 10 | 105 |
| 2014 Junho | 67 | 6 | 73 |
| 2014 Maio | 86 | 13 | 99 |
| 2014 Abril | 66 | 7 | 73 |
| 2014 Maro | 95 | 12 | 107 |
| 2014 Fevereiro | 129 | 15 | 144 |
| 2014 Janeiro | 106 | 19 | 125 |
| 2013 Dezembro | 90 | 14 | 104 |
| 2013 Novembro | 87 | 21 | 108 |
| 2013 Outubro | 62 | 19 | 81 |
| 2013 Setembro | 106 | 38 | 144 |
| 2013 Agosto | 20 | 9 | 29 |
Mostrar tudo
