[A case of radiation-induced coronary occlusion treated with elective and emergency PTCA]

We describe the case of a patient (pt) treated with radiotherapy for Hodgkin's lymphoma at the age of 17. Two years later he presented an apical AMI and underwent coronary angiography (CA) for postinfarction angina. A 40% stenosis of the left anterior descending (LAD) was found in the proximal portion and the vessel was occluded at the middle level. Septal and diagonal branches supplied collaterals to the distal LAD and left ventricular function was only mildly reduced (EF angio-ventriculographic = 52%). We successfully performed a first PTCA, but the pt was re-admitted to our hospital few days later for a new large anterior myocardial infarction with refractory hypotension and low output condition. An intraaortic balloon catheter was inserted and CA demonstrated proximal LAD occlusion; a new PTCA was then performed and the opening of the vessel was obtained after 90' from symptoms' onset. The subsequent course was uneventful and the pt was discharged after 20 days. The ejection fraction was 39%. Thirty days after, a third PTCA with Palmaz-Schatz stent implantation was necessary for unstable angina due to a restenosis of the proximal LAD. After ten months follow-up the pt is asymptomatic with negative exercise test and an angioscintigraphic EF = 47%. CA and intravascular ultrasound demonstrated nor restenosis or progression of the disease, with a good minimal luminal diameter (MLD). A review of the literature on this topic is presented. Moreover we discuss the mechanism of coronary stenosis and occlusion and the reasons for choosing PTCA in the various settings.