Treatment of Spontaneous Left Main Coronary Artery Spasm with

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					Case Report                                                                                           Acta Cardiol Sin 2009;25:43-6

           Treatment of Spontaneous Left Main Coronary
              Artery Spasm with a Drug-Eluting Stent
                                            Hsin-Hua Chou,1 Kun-Eng Lim2 and Yu-Lin Ko1

     Variant angina due to spontaneous left main trunk spasm is rarely reported in the literature. Despite intensive
     medical treatment or surgical intervention, patients may still suffer from recurrent symptoms. We describe a
     70-year-old male patient who had spontaneous left main coronary artery spasm with recurrent angina. The patient
     was successfully treated with a drug-eluting stent and remained free of symptoms at a 2-year clinical follow-up.

     Key Words:         Variant angina · Left main trunk spasm · Drug-eluting stent

INTRODUCTION                                                                cessfully treated with a drug-eluting stent with good
                                                                            long-term (i.e., two-year) results, suggesting that drug-
    Coronary artery vasospasm plays an important role                       eluting stents are a viable treatment option for isolated
in the genesis of variant angina. It primarily occurs in                    left main trunk (LMT) spasm.
the right coronary artery, and less commonly in the left
anterior descending coronary artery.1 While patients with
variant angina suffer recurrent episodes of chest pain,                     CASE REPORT
long-term survival is excellent for those diagnosed with
variant angina.2 In contrast, if the angina is a result of                       A 70-year-old man presented with history of progres-
spontaneous spasm in the left main coronary artery,                         sive angina pain that occurred while exercising and at rest
rarely reported in the literature, patients may experience                  for 10 months’ duration. The patient reported no health
malignant ventricular fibrillation and even sudden                          concerns until several years before this examination,
death.3,4 Moreover, despite intensive medical treatment                     when he began to suffer from precordial chest tightness
with nitrate and calcium channel blocker, some of these                     with exertion. His chest discomfort usually persisted for
patients still have refractory angina. Oftentimes, coro-                    several minutes and could only be relieved by rest or
nary artery bypass surgery or surgical coronary angio-                      sublingual nitroglycerin. Since early 2004, the episodes
plasty is required in this subset of patients. Here, a case                 of chest discomfort had increased in frequency and were
of refractory angina caused by spontaneous left main                        often associated with cold sweats. The patient had his-
coronary artery spasm is described. The lesion was suc-                     tory of hyperlipidemia but reported no other ailments.
                                                                                 Clinical examination was unremarkable, and the
                                                                            resting electrocardiogram showed a sinus rhythm. A
Received: January 9, 2008       Accepted: May 5, 2008                       treadmill exercise test with Bruce protocol was per-
  Division of Cardiology, Department of Internal Medicine; 2Depart-         formed, but stopped at the seventh minute at a heart rate
ment of Radiology, Buddhist Tzu Chi General Hospital, Taipei
                                                                            of 144 beats/min, due to severe angina, marked horizon-
Branch, 289 Jianguo Road, Xindian City, Taipei 231, Taiwan.
Address correspondence and reprint requests to: Dr. Yu-Lin Ko, Divi-        tal ST-segment depression in the inferolateral leads and
sion of Cardiology, Department of Internal Medicine, Buddhist Tzu           3-mm ST segment elevation at aVR, and a drop of sys-
Chi General Hospital, Taipei Branch, 289 Jianguo Road, Xindian
                                                                            tolic blood pressure from 181 mmHg to 93 mmHg.
City, Taipei 231, Taiwan. Tel: 886-2-6628-9779 ext. 5709; Fax: 886-
2-6628-9009; E-mail:                                      Coronary arteriography by Judkin’s technique was

                                                                       43                                   Acta Cardiol Sin 2009;25:43-6
                                                          Hsin-Hua Chou et al.

performed due to the strong evidence suggestive of myo-                     tion of the left anterior descending artery and the proxi-
cardial ischemia. Selective right coronary angiography                      mal portion of the left circumflex artery. This interven-
revealed patent right coronary artery (Figure 1A), and a                    tion completely relieved the patient’s angina.
patent left main trunk was noted when contrast medium                            Post-stenting, the patient was prescribed long-acting
was injected without selective engagement of the left                       nitrate and calcium channel blockers. Angiography, re-
coronary artery. A significant spasm over the proximal                      peated at 2 weeks and 6 months post-stenting, revealed a
left main trunk was noted when the Judkin left catheter                     patent coronary tree without evidence of restenosis (Fig-
selectively engaged in the left coronary artery (Figure                     ure 2C). A treadmill exercise test performed 1 year later
1B). Sublingual nitroglycerin was administered to the                       showed no evidence of myocardial ischemia, and a com-
patient, and an improvement in the patient’s discomfort                     puted tomography angiogram of coronary arteries, also
was noted. The selective left coronary angiography was                      performed 1 year after stenting, revealed patent coronary
then repeated and a patent left main coronary artery was                    arterial trees, including the stented segment of the left
noted (Figure 2A). The catheter was removed since the                       main coronary artery (Figure 2D). The patient remained
procedure was complete. However, the patient suddenly                       asymptomatic at 2-year follow-up.
developed severe chest pain in the catheterization labo-
ratory, and his blood pressure decreased to 76/44 mmHg.
Repeat coronary angiography revealed an extreme nar-                        DISCUSSION
rowing of the left main coronary artery again. Intra-
vascular ultrasound was performed to evaluate the left                           The prognosis of patients with coronary artery spasm
main coronary artery lesion, and no dissection or athero-                   in the absence of significant coronary artery disease ap-
sclerotic lesion of the left main coronary artery was                       pears to be relatively good. In a large series of 277 pa-
identified. Since the patient had recurrent chest pain as-
sociated with hypotension in the absence of catheter, a
presumptive diagnosis of left main coronary artery
spasm was made.
     The decision was made to perform direct stenting
using a drug-eluting stent to treat the left main coronary
artery spasm. After successful wiring of the left anterior
descending artery and left circumflex artery via a 6
French Judkin left catheter, a Taxus 3.5 ´ 16-mm stent
(Boston Scientific, Natick, MA) was deployed in the left
main coronary artery and left anterior descending artery
directly (Figure 2B). Kissing balloon technique was ap-
plied for the left main coronary artery, the proximal por-

                                                                            Figure 2. (A) Following administration of sublingual nitroglycerin,
                                                                            the spasm of the proximal left main trunk has been relieved. (B) Coro-
                                                                            nary angiogram after Taxus drug-eluting stent deployment. The left
                                                                            main coronary artery is patent. (C) Coronary angiogram 6 months fol-
                                                                            lowing placement of the drug-eluting stent. The left main trunk remains
Figure 1. Selective coronary angiogram showing (A) a patent right           patent without evidence of restenosis. (D) Computed tomography
coronary artery, and (B) extreme narrowing of the proximal left main        angiogram performed at the 1-year follow-up demonstrating persistent
trunk.                                                                      patency of the left main coronary artery.

Acta Cardiol Sin 2009;25:43-6                                          44
                          Drug-Eluting Stent in Treatment of Left Main Coronary Artery Spasm

tients with a median follow-up of 7.5 years, cardiac death          ten case reports, seven patients were treated medically
and myocardial infarction were relatively infrequent and            (i.e., calcium channel blockers and/or nitrates) and five
occurred in 3.5% and 6.5% of patients, respectively.                patients were managed surgically, either with coronary
However, recurrent angina was commonly reported, and                artery bypass graft or surgical angioplasty. Not one of
occurred in 39% of patients.5 While long-acting calcium             these patients was treated via coronary angioplasty,
antagonist, nitrates and nicorandil are frequently em-              which makes the case described above truly unique. Fur-
ployed for symptom relief, ultimately, medical treatment            ther, our patient with severe spontaneous left main coro-
is usually ineffective. Indeed, in a study performed by             nary artery spasm treated with a Taxus drug-eluting stent
Sueda et al., up to 42% of patients with pure coronary              enjoyed long-term relief from his condition.
spastic angina had more than one attack per month irre-                  To our knowledge, this is the first patient with iso-
spective of the administration of calcium antagonist or             lated spontaneous left main coronary artery spasm suc-
isosorbide dinitrate.6 Increasing the dosage of these me-           cessfully managed with a drug-eluting stent. Thus, this
dications may alleviate the anginal symptom; however,               technique should be considered as a viable option for
adverse effects due to higher doses or different combina-           isolated LMT spasm, and further research using this mo-
tions of agents may lead to discontinuation of therapy.             dality is encouraged. While there may be some criticism
     When medical therapy is ineffective in symptom con-            about the procedure, such as recurrent spasm in other
trol for patients with variant angina, surgical intervention        site of coronary artery, and possible subacute and late
is usually considered. Coronary artery bypass grafting              thrombosis of drug-eluting stents, we believe that for pa-
with saphenous vein or internal mammary artery is the               tients with severe isolated left main coronary artery
most commonly recommended surgical procedure. How-                  spasm who have recurrent symptoms and who are in
ever, results have been variable in that higher rates of re-        high risk of sudden cardiac death and malignant cardiac
current angina and graft occlusion have been reported,              arrhythmia, coronary angioplasty with the implantation
especially when the saphenous vein is used for grafting.7           of a drug-eluting stent in combination with medical
     Surgical angioplasty with plexectomy is another op-            treatment provide an alternative treatment option.
tion for the surgical management of variant angina.8 This
technique is preferred to conventional coronary artery
bypass grafting because it results in a more physiologic            REFERENCES
perfusion of the coronary tree and prevents competitive
flow risk. The long-term clinical outcome of this tech-              1. Pepine CJ, el-Tamimi H, Lambert CR. Prinzmetal’s angina (vari-
nique, however, remains controversial.                                  ant angina). Heart Dis Stroke 1992;1:281-6.
     Coronary angioplasty is another choice of treatment              2 Yasue H, Takizawa A, Nagao M, et al. Long-term prognosis for
in patients with coronary artery spasm superimposed on                  patients with variant angina and influential factors. Circulation
atherosclerotic narrowing. Although high procedural
                                                                     3. Tzivoni D, Merin G, Milo S, Gotsman MS. Spasm of left main
success rates are reported, recurrent symptoms due to
                                                                        coronary artery. Br Heart J 1976;38:104-7.
coronary spasm usually persist or recur, often accompa-              4. Rumoroso JR, Inguanzo R, Cembellin JC, et al. Left main coro-
nied with restenosis. Intracoronary stent implantation                  nary artery spasm. Int J Cardiol 1995;51:202-3.
represents an attractive therapeutic option in patients              5. Bory M, Pierron F, Panagides D, et al. Coronary artery spasm in
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tional medical therapy. The therapeutic effect of stent-                follow-up of 277 patients. Eur Heart J 1996;17:1015-21.
                                                                     6. Sueda S, Kohno H, Fukuda H, et al. Limitations of medical ther-
ing, however, is potentially limited by the stimulation of
                                                                        apy in patients with pure coronary spastic angina. Chest 2003;
neointimal proliferation and the occurrence of spasm at
the unstented sites along the length of the vessel, and              7. Gaasch WH, Lufschanowski R, Leachman RD, Alexander JK.
possibly at the stent-edge.9-11                                         Surgical management of Prinzmetal’s variant angina. Chest
     Isolated spontaneous left main coronary artery spasm               1974;66:614-21.
is rarely reported in the literature. Of the twelve patients         8. Sen RC, Hitter E, Ranquin R, et al. Surgical coronary angioplasty
with isolated left main coronary artery spasm included in               for left main vasospasm. Am Heart J 1995;129:399-400.

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                                                          Hsin-Hua Chou et al.

 9. Gaspardone A, Tomai F, Versaci F, et al. Coronary artery stent              tery spasm. Catheter Cardiovasc Interv 2002;56:16-20.
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    treatment. Am J Cardiol 1999;84:96-8, A8.                                   spasm after stent implantation in patients with or without vaso-
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Acta Cardiol Sin 2009;25:43-6                                          46

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