Beyond the Blockage: Coronary Artery Disease with a Twist

The latest focus issue of CASE is now available exploring coronary artery disease, including “Embolic Myocardial Infarction from Takayasu Arteritis” by Lam et al. CASE Editor-in-Chief Vincent Sorrell, MD, FASE, remarked, “In a busy clinical practice, atypical coronary pathologies could get overlooked for the much more common garden-variety CAD: atherosclerosis. Lam et al. provide readers with a very interesting CASE report in a 42 year old woman with an out-of-hospital cardiac (ventricular fibrillation) arrest and associated acute anterior STEMI. During coronary angiography, the coronary arteries were non-diseased except for a totally occluded LAD with the angiographic appearance of a thrombus. They offer readers their approach to both diagnosis and management. They concluded that this represented Takayasu arteritis (TAK) and their presentation and discussion nicely provide readers with their thoughtful approach. They prepared a table with imaging criteria used to assist in this diagnosis. There are excellent TTE, TEE (NOTE: these are must see videos), CCT, CMR and MRA images. The authors highlight the complicated clinical course and associated risks of TAK. They also give readers follow up findings over many years.  In the end, this is an important CASE as it (in the authors’ own words) “highlights the challenges associated with diagnosing TAK due to its subtle clinical presentation and the absence of definitive diagnostic tools.”

This focus edition continues to highlight coronary artery disease, a common disease with uncommon presentations. While coronary pathology is frequently encountered this issue reminds us that its manifestations can extend well beyond the familiar. Zalaquett et al. highlights the importance of echocardiographic detection of an intra-atrial right coronary artery, an extremely rare, but benign subtype of coronary artery anomalies. Desai et al. further highlights diagnostic challenges through their investigation of an anomalous left coronary artery arising from the right pulmonary artery. Seifer et al. describe a rare right coronary artery–to–superior vena cava fistula complicated by infective endocarditis, illustrating the intricate interplay between structural abnormalities and infectious processes. Ardhanari et al. presents a striking case of congenital left main coronary artery atresia in a pediatric patient, highlighting the critical role of multimodality imaging in identifying rare congenital coronary anomalies. In contrast, Akiash et al. describe an unusual adult presentation, a large intrapericardial cystic lymphangioma encircling the right coronary artery, an entity seldom encountered in clinical practice. Together, these reports underscore the importance of vigilance, advanced imaging, and thoughtful interpretation when evaluating coronary disease across the age spectrum.

Readers can look forward to Dr. Sorrell’s editorial, which dissects the many direct and indirect abnormalities of the coronary arteries beyond conventional atherosclerosis.

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