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Coronary artery bypass with saphenous vein graft in a middle-aged patient with polyarteritis nodosa/Poliarteritis nodosa olan orta yasta bir hastada safen ven grefti ile koroner arter baypas.



Dear Editor,

We report a case of poliateritis nodosa (PAN) with coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue.  (CAD) who underwent coronary bypass surgery Coronary bypass surgery
A surgical procedure which places a shunt to allow blood to travel from the aorta to a branch of the coronary artery at a point past an obstruction.

Mentioned in: Cardiac Catheterization, Thallium Heart Scan
 with saphenous vein graft. Poliateritis nodosa is a multisystemic mul·ti·sys·tem·ic
adj.
Relating to a disease or condition that affects many organ systems of the body.



multisystemic

affecting more than one body system.
 disease with necrotizing necrotizing /nec·ro·tiz·ing/ (nek´ro-tiz?ing) causing necrosis.
Necrotizing
Causing the death of a specific area of tissue. Human bites frequently cause necrotizing infections.
 vasculitis of the middle and large sized arteries. In the usual clinical course, renal and visceral vascular involvement is typical (1,2). Most of patients with PAN have positive angiographic evidence, predominantly in the visceral arteries but also in the extremity arteries and in the small aortic branches. The most well-known angiographic feature is the presence of microaneurysms in medium or small arteries. Arterial occlusive lesions are also a feature, but their frequency is not reported (2,3). Especially in young patients without any cardiovascular risk factors, premature CAD may be associated with an underlying vasculitis syndrome (1,4).

This 36-years-old male patient had been followed with the diagnosis of PAN for seven years with no prior cardiac symptoms. He admitted to hospital with new onset chest pain. Electrocardiography (ECG) revealed acute myocardial ischemic Ischemic
An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery.

Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation


ischemic
 changes. The patient was also in the chronic renal insufficiency phase. Echocardiography Echocardiography Definition

Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart muscle. Ultrasound waves that rebound or echo off the heart can show the size, shape, and movement of the heart's valves and
 revealed normal ventricular wall motion and mild mitral regurgitation, ejection fraction was 66%. Coronary angiography showed 90% stenosis in proximal left anterior descending (LAD) and total occlusion of right coronary artery (RCA) (Fig. 1, 2). The patient underwent coronary artery bypass grafting.

[FIGURES 1-2 OMITTED]

Due to arterial involvement of PAN we decided to use venous graft for revascularization. The left vena saphena magna was explored and harvested, the diameter was large enough and no segmental involvement and/or evidence related to vasculitis were observed. Cardiopulmonary bypass (CPB) was commenced at 2.4 L/min/m2 with normothermia normothermia /nor·mo·ther·mia/ (-therm´e-ah) a normal state of temperature.normother´mic

nor·mo·ther·mi·a
n.
1. A condition of normal body temperature.

2.
. Blood cardioplegia was administered for every 15 minutes. An end-to-side LAD and RCA revascularization was performed with vena saphena magna graft. The postoperative period was uneventful and the patient was discharged on the seventh day.

Premature CAD is an important predictor of overall morbidity and mortality in patients with vasculitis syndromes. Differential diagnosis has to be made with other vasculitis, such as systemic lupus erythematosus Systemic Lupus Erythematosus Definition

Systemic lupus erythematosus (also called lupus or SLE) is a disease where a person's immune system attacks and injures the body's own organs and tissues. Almost every system of the body can be affected by SLE.
, Kawasaki's disease, Behget's disease and Takayasu arteritis arteritis

Inflammation of the arteries. It occurs in diseases including syphilis, tuberculosis, and lupus erythematosus. Varieties not closely associated with systemic disease or disease of an organ outside the cardiovascular system have been described as temporal arteritis,
 (3-6). Coronary artery involvement (76%) ranks second in frequency behind the renal arteries (85%). Polyarteritis nodosa affects the coronary arteries in 50% of the patients and microscopically, all layers of the arterial wall are involved. Thrombosis, aneurysms, and arteritis of the coronary vessels are known complications of the disease (3). But, it is unlikely to be the underlying disease in the present patient due to absence of inflammatory lesions in the aorta or its major branches. These lesions did not seem to be congenital or atherosclerotic, and it was postulated that these lesions might have been the sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention  of PAN. Signs and symptoms of coronary arteritis included hypertension (most common), tachycardia, congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. , murmurs, cardiomegaly cardiomegaly /car·dio·meg·a·ly/ (-meg´ah-le) abnormal enlargement of the heart.

car·di·o·meg·a·ly
n.
Enlargement of the heart. Also called macrocardia, megalocardia.
, pericardial friction rubs, and arrhythmias.

In English language literature, experience about the appropriate graft selection and the long-term results of patency are reported for vasculitis syndromes such as Kawasaki disease, Behcet's disease and Takayasu arteritis but there were no data for PAN (1, 3, 5, 6). In this young patient, venous graft was preferred for coronary artery revascularization due to susceptibility to inflammatory reaction to arterial graft.

Appropriate antihypertensive, antilipidemic and antiaggregant medications must be added to the medical treatment of primary disease and known risk factors for premature coronary artery disease must be eliminated or controlled. These precautions will protect the native coronary arteries and will also increase the patency rates of the grafts used for revascularization.

References

(1.) Cassling RS, Lortz JB, Olson DR, Hubbard TF, McManus BM. Fatal vasculitis (periarteritis nodosa) of the coronary arteries: angiographic ambiguities and absence of aneurysms at autopsy. J Am Coll Cardiol 1985; 6: 707-14.

(2.) Stanson AW, Friese JL, Johnson CM, McKusick MA, Breen JF, Sabater EA, Andrews JC. Polyarteritis nodosa: spectrum of angiographic findings. Radiographics 2001; 21: 151-9.

(3.) Chu KH, Menapace FJ, Blankenship JC, Hausch R, Harrington T. Polyarteritis nodosa presenting as acute myocardial infarction acute myocardial infarction (·kyōōtˑ mī·ō·karˑ·dē·  with coronary dissection. Cathet Cardiovasc Diagn 1998; 44: 320-4.

(4.) Ahronheim JH. Isolated coronary periarteritis: report of a case of unexpected death in a young pregnant woman. Am J Cardiol 1977; 40: 287-90.

(5.) Tanaka M, Abe T, Takeuchi E, Watanabe T, Tamaki S. Revascularization for coronary ostial stenosis in Takayasu's disease with calcified Calcified
Hardened by calcium deposits.

Mentioned in: Heart Valve Repair
 aorta. Ann Thorac Surg 1992; 53: 894-5.

(6.) Tsuda E, Kitamura S; Cooperative Study Group of Japan. National survey of coronary artery bypass grafting for coronary stenosis caused by Kawasaki disease in Japan. Circulation 2004;110: 61-6.

Address for Correspondence: Halil Ibrahim Ucar, MD, Duygulu sk. No: 45/4 Aydinlikevler 06130 Ankara, Turkey

Tel.: +90 312 305 17 74 Fax: +90 312 311 73 77 E-mail: hiu@hacettepe.edu.tr

Halil Ibrahim Ugar, Mehmet Oc, Mustafa Tok, Arda Ozyuksel, Bahar Oc *, Bora Farsak

From Departments of Cardiovascular Surgery and * Anesthesiology, Hacettepe University, Faculty of Medicine, Sihhiye, Ankara, Turkey
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Title Annotation:Letter to the Editor/Editore Mektup
Author:Ucar, Halil Ibrahim; Oc, Mehmet; Tok, Mustafa; Ozyuksel, Arda; Oc, Bahar; Farsak, Bora
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Geographic Code:7TURK
Date:Jun 1, 2007
Words:812
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