Intractable Coronary Spasm Requiring Percutaneous Coronary Intervention after Coronary Artery Bypass Grafting in a Patient with Moyamoya Disease

Abstract

Moyamoya disease (MMD) is characterized by progressive steno-occlusive lesions of the distal or proximal branch of the internal carotid arteries, and cerebrovascular symptoms are its major complications. Extracranial vascular involvement including the coronary artery has been reported, and some case reports have described variant angina or myocardial infarction. However, no report has yet described a case of myocardial infarction after coronary artery bypass grafting (CABG). Here, we present a patient with MMD who suffered cardiac arrest caused by myocardial infarction due to a coronary spasm after offpump CABG and who was discharged successfully after treatment with a veno-arterial extracorporeal membrane oxygenator and percutaneous coronary intervention.

Keywords: Coronary artery bypass surgery; Coronary artery disease; Coronary vasospasm; Moyamoya disease.

Fig. 1

Preoperative brain magnetic resonance angiography and transfemoral cerebral angiography. (A) Steno-occlusive lesion of the left distal internal carotid artery (white arrow). (B) At the distal part of the steno-occlusive lesion, there are areas of collateral circulation like a puff of smoke (white star).

Fig. 2

Preoperative coronary angiography of unstable angina with 2-vessel disease. (A) Chronic total occlusive lesion in the left anterior descending artery and proximal 90% stenosis of the left circumflex artery. (B) A 50% stenosis lesion of the right coronary artery.

Fig. 3

Coronary artery angiography after extracorporeal membrane oxygenator insertion. (A) An intractable vasospastic lesion in the right coronary artery not relieved by repeated intracoronary nitroglycerin injections (white arrow). (B) Successful percutaneous coronary intervention with stent implantation in the right coronary artery (black arrow).