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要旨
患者は63歳男性で,約9年前に他院で左冠動脈近位部の90%狭窄病変に対してバルーンによる経皮的冠動脈形成術(PCI)を施行.PCIから3カ月後の造影では再狭窄はなく,以後通院を自己中断していた.1999年10月に労作時の胸部絞扼感が出現し当科を初診し,狭心症の疑いで入院となった.同年10月12日に施行した冠動脈造影で約9年前のPCI施行部位に一致し巨大冠動脈瘤を認めたため,抗凝固療法やスタチンによる脂質コントロールを開始した.その3カ月後の冠動脈造影で瘤の末梢に新たな狭窄病変が出現したが,負荷心筋シンチで虚血を示す所見がなく経過観察となった.当院初回入院から7カ月後の再造影で,冠動脈瘤増大は認めなかったが,その末梢の狭窄が60%から90%に進行していた.PCIによる治療も考慮されたが,冠動脈バイパス手術と瘤切除を希望し無事手術が施行された.この期間強力に脂質低下療法を行っていたにもかかわらず冠動脈瘤の末梢に狭窄病変が出現,進展した経過に冠動脈瘤の存在が何らかの影響を与えた可能性が考えられ,凝固系の異常やshear stressの関与が示唆された.
Summary
A 63-year-old man was admitted to our hospital because of recurrence of angina. Nine years previously,he underwent percutaneous coronary balloon angioplasty for a stenotic lesion in LAD #6 proximal in another hospital. Three months after angioplasty,re-stenosis was not noticed angiographically. After that,he discontinued going to the hospital,and received no medical treatment. In our hospital,coronary angiography revealed a giant coronary aneurysm in the previously treated lesion. Once again,he was given medical treatment for anti-coagulation,anti-platelet and hyperlipidemia by a statin. Three months later,coronary angiography revealed a new stenotic lesion in the distal section of the coronary aneurysm,but stress myocardial scintigraphy showed no myocardial ischemia. Seven months later,coronary angiography showed rapid progression of the stenotic lesion from 60% to 90%. The patient selected CABG and resection of the aneurysm rather than percutaneous coronary intervention,and the operation was performed successfully. In this period,the serum lipid level was controlled very well. Nevertheless,a new stenotic lesion appeared and progressed rapidly. It was suggested that the presence of the giant aneurysm influenced the rapid progression of coronary plaque by the abnormality of the coagulation system and shear stress.
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