Document Detail

Percutaneous transluminal coronary angioplasty for coronary artery stenosis in a young patient with long term Kawasaki Disease.
Jump to Full Text
MedLine Citation:
PMID:  16134779     Owner:  NLM     Status:  MEDLINE    
Kawasaki Disease (KD) is an acute, febrile, multisystem disease of children. More severe complications in 15-25% of cases include, the development of coronary aneurysms, ischemic heart disease, and sudden cardiac death. The standard treatment for significant coronary artery stenosis has generally been aortocoronary bypass surgery, although percutaneous transluminal coronary angioplasty (PTCA) has been described in a small number of patients. This report describes a 14 year old boy with a history of KD who developed multiple coronary aneurysms and stenosis. We performed PTCA, which was successful in relieving the stenosis of the left circumflex artery.
Seok In Hong; Pum Joon Kim; Ki Bae Seung; Jung Hyun Kwon; Ju Yeal Beak; Chang Dong Yeo; Kyu Bo Choi
Related Documents :
17197719 - Ostial rca intervention: guiding catheter challenges and use of a buddy wire to perform...
1891739 - External iliac artery rupture during angioplasty: control by balloon tamponade.
2942609 - Light and electron microscopic study of pathomorphological changes on the arterial wall...
21620009 - Double-barreled cannon stent grafts: possible solution for extremely dilated landing zo...
7892459 - Long-segment (> or = 10 cm) femoropopliteal angioplasty: improved technical success and...
6237579 - Percutaneous transluminal coronary angioplasty.
14652839 - Does the sequence of clamp application during open abdominal aortic aneurysm surgery in...
11237789 - Can ultrasound replace arteriography in the management of chronic arterial occlusive di...
6507759 - Dilemmas in dealing with the blue toe syndrome: aortic versus peripheral source.
Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  The Korean journal of internal medicine     Volume:  20     ISSN:  1226-3303     ISO Abbreviation:  Korean J. Intern. Med.     Publication Date:  2005 Jun 
Date Detail:
Created Date:  2005-09-01     Completed Date:  2005-09-29     Revised Date:  2014-06-05    
Medline Journal Info:
Nlm Unique ID:  8712418     Medline TA:  Korean J Intern Med     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  187-90     Citation Subset:  IM    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Angioplasty, Balloon, Coronary*
Coronary Aneurysm / diagnosis,  etiology,  therapy
Coronary Angiography
Coronary Stenosis / diagnosis,  etiology,  therapy*
Coronary Vessels / ultrasonography
Follow-Up Studies
Mucocutaneous Lymph Node Syndrome / complications*,  diagnosis

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Korean J Intern Med
Journal ID (iso-abbrev): Korean J. Intern. Med
Journal ID (publisher-id): KJIM
ISSN: 1226-3303
ISSN: 2005-6648
Publisher: The Korean Association of Internal Medicine
Article Information
Download PDF
Copyright © 2005 The Korean Association of Internal Medicine
Received Day: 04 Month: 9 Year: 2004
Accepted Day: 30 Month: 11 Year: 2004
Print publication date: Month: 6 Year: 2005
Electronic publication date: Day: 30 Month: 6 Year: 2005
Volume: 20 Issue: 2
First Page: 187 Last Page: 190
PubMed Id: 16134779
ID: 3891393
DOI: 10.3904/kjim.2005.20.2.187

Percutaneous Transluminal Coronary Angioplasty for Coronary Artery Stenosis in a Young Patient with Long Term Kawasaki Disease
Seok In Hong, M.D.A1
Pum Joon Kim, M.D.A1
Ki Bae Seung, M.D.A1
Jung Hyun Kwon, M.D.A1
Ju Yeal Beak, M.D.A1
Chang Dong Yeo, M.D.A1
Kyu Bo Choi, M.D.A1
Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea.
Correspondence: Correspondence to: Ki Bae Seung, M.D., Department of Internal Medicine, The Catholic University, 505 BanPo-dong, Seocho-gu, Seoul 137-701, Korea. Tel: 82-2-590-2075, Fax: 82-2-591-1075,


Kawasaki Disease, first described in 1967, is a serious childhood illness characterized by high fever, conjunctivitis, erythema of oral mucosa and pharynx, a "strawberry" tongue, diffuse inflammation of both hands and often feet, polymorphous desquamative rash, and acute non-purulent cervical lymphadenopathy. In the absence of laboratory measurements, KD is diagnosed when five of the six symptoms are identified. Alternatively, the disease may also be diagnosed if coronary aneurysms are found in addition to four of the major symptoms. In some patients, the long-term sequelae of vasculitis occurring in KD results in coronary artery aneurysms, thrombotic occlusions, progression to ischemic heart disease, and/or premature arteriosclerosis5-7). Approximately 4% of coronary aneurysms subsequently develop stenotic lesions, half of which occur within 2 years of the onset of KD6). The standard treatment for significant coronary artery stenosis has generally been aortocoronary bypass surgery1,2), although PTCA has been described in a small number of patients3,4). We describe here a 14 year old male with KD who developed stenosis of the coronary arteries, which was successfully managed with PTCA.


A 14-year-old boy was admitted to our institution for elective PTCA to relieve stenosis of the coronary arteries. At 4 years and 7 months of age, the patient presented to our institution with typical signs and symptoms of KD (persistent fever up to 39℃ for 10 days accompanied with conjunctival injection and a strawberry tongue). Consequently, the patient received intravenous gamma globulin and aspirin, which resulted in a prompt resolution of the fever and improvement of symptoms. Two-dimensional echocardiography performed during the acute phase of the illness demonstrated fusiform aneurysms of the right coronary artery (RCA) (10 mm in diameter), left anterior descending (LAD) branch (7 mm), and left circumflex (3.7 mm), as well as dilatation of the left main coronary artery (LMCA) (4 mm). However, there was normal systolic ventricular function without regional wall motion abnormalities. The patient was given low-dose aspirin and discharged from the institution. After discharge the patient was free of symptoms. An echocardiogram performed 15 months after the onset of illness demonstrated mildly improved fusiform aneurysms of the RCA (8.4 mm) and LAD (5 mm), as well as improved dilatation of LMCA (3.4 mm). However, there was no change in the left circumflex lesion. The patient was continued on a therapy of low-dose aspirin and remained asymptomatic. A 24 hour Holter monitor at 20 months, 40 months, and 68 months after presentation indicated normal heart rhythm with no evidence of ischemia. A treadmill test performed 9 years after presentation revealed no arrhythmias or ischemic changes. Nine years and 5 months after disease onset, selective coronary angiography revealed two saccular aneurysms in the proximal portion of the LAD, and in the proximal portion of the RCA as well as stenosis (minimal lesion in the proximal portion of the LAD, discrete lesion in the left circumflex, and total obstruction in the RCA with collateral arteries supplying blood to the distal portion of the RCA.)(Figure 1). The patient retrospectively reported symptoms of intermittent chest discomfort for 5 months prior to catheterization. On admission, his blood pressure was 120/80 mmHg. His heart rhythm was regular and his heart rate was 76 bpm. The patient looked well and his physical examination and laboratory results did not reveal any abnormalities. Accordingly PTCA was performed at 9 years and 6 months after the onset of illness. The procedure employed a 3.5 mm balloon catheter in the stenotic lesion of the proximal portion of the left circumflex. The balloon was then inflated with diluted contrast medium to a pressure of 10 atm. The area of stenosis was 80% before PTCA and there was no residual stenosis after PTCA (Figure 2). An intravascular ultrasound (IVUS) study was performed immediately after PTCA. The IVUS imaging revealed a calcified lesion and atheroma at the site of the left circumflex coronary artery (Figure 3). The patient tolerated the procedure well with no electrocardiographic changes. He was discharged home on aspirin, ticlopidine, and isosorbide dinitrate. To date, he has been well. Currently, the patient is following a regimen of low-dose aspirin.


Kawasaki Disease is an acute febrile illness occurring most often in infants and children. Fifteen to twenty percent of cases develop more severe complications including coronary aneurysms, ischemic cardiac disease, and sudden cardiac death. US epidemiologic studies of KD demonstrate the peak incidence of disease to be at 18 to 24 months of age, with children ≤5 years of age accounting for approximately 80% to 85% of cases. Surveys conducted in the study indicate that the male-to-female ratio is 1.3-1.5:1 in KD, whereas the male-to-female ratio is 4:1 in their study of the hemodynamic and coronary angiographic findings in children with KD with obstructive coronary lesions8).

The major long-term concerns of KD are the development of coronary artery lesions that may manifest as aneurismal lesions, thrombotic occlusions with progression to ischemic heart disease, and the development of premature arteriosclerosis5-7). Currently, with appropriate medical management (immunoglobulins and salicylates), about 4% of children with KD eventually develop ischemic heart disease, which is often associated with calcified stenosis during long-term follow up3,6,9). Since the disease was first described by Kawasaki in 1967, the mortality rate has decreased attributable, in large part, to the development of advanced diagnostic methods and treatment6). However, coronary artery aneurysm, a serious complication of KD, has remained a leading cause of acquired heart disease in children10). Therefore, the prognosis of KD correlates with the degree of coronary involvement. Kato and colleagues3) have reported the results of serial coronary angiography to clarify the fate of coronary aneurysms. Serial angiographic follow-up of KD patients has indicated that approximately 50% of 42 patients with coronary artery abnormalities showed resolution 5 to 18 months later, with giant aneurysms (defined as ≥8 mm in diameter) the least likely to regress and most likely to progress to stenosis8). The regression in coronary aneurysms was recognized within one or two years after onset; however, half of the patients with regressed coronary aneurysms continued to demonstrate a dense or bright echo in the coronary artery wall on a 2D-echocardiography6). The mechanism of coronary artery stenosis in KD is uncertain. One possibility is acute occlusion by massive thrombus formation in the coronary aneurysm, which occurs mostly in acute or subacute stages of illness. Another mechanism of coronary artery stenosis in KD may be the progression of marked thickening of the intima often associated with calcification, which is similar to an arteriosclerotic lesion11,12). The risk factors for progression to ischemic heart disease are giant aneurysm (diameter of more than 8 mm), a saccular aneurysm shape, prolonged fever for more than 21 days, and age at onset of less than 2 years13).

Interventions such as PTCA, atherectomy, or stent implantation are now common treatments for adults with coronary artery disease14,15). However the use of these treatments is limited in KD4). In particular, PTCA is not as effective in KD patients as in others because the stenotic lesions in long-term KD are stiff and often associated with calcification. Aortocoronary bypass surgery is the standard therapy for severe stenosis of coronary arteries with lesions that form as a result of KD1,2,16-18). Bypass surgery is indicated in cases with multiple vessel lesions, cases with severe valvular disease, and cases with severe left ventricular dysfunction19). The long-term patency of bypass grafts is satisfactory in older patients but remains unsatisfactory in young children with KD. Therefore, PTCA should be considered in young children to postpone bypass surgery until patients are of sufficient age and size, so that the bypass grafts are likely to maintain satisfactory long-term patency. Recent advances in intravascular ultrasound (IVUS) imaging have allowed pathological evaluation of the vascular wall structure of coronary stenosis12,20). Recently Ino and colleagues4) reported that the only predictor of successful PTCA seemed to be the elapsed time from the onset of KD to the performance of PTCA: PTCA performed within 6 to 8 years after onset of the disease is more likely to lead to successful dilatation, which means that stenotic lesions may develop arteriosclerotic changes in the long term. Factors such as age at onset, lesion site, sex, clinical symptoms, and presence or absence of a perfusion defect on a 201Thallium scintiscan did not appear to affect outcome of PTCA.

Our successful attempt may indicate that this procedure should be considered early in subclinical stenosis to prevent ischemic cardiac damage. We suggest that PTCA may successfully dilate stenotic coronary arteries that have relatively soft intima with only localized mild calcification. IVUS is useful in the assessment of wall morphology and tissue characterization of the pathological coronary artery as well as in the selection of the best device for interventional treatment. A catheter intervention for coronary artery stenotic lesions in KD demonstrated significant therapeutic effects in the short term. Intervention with a catheter is a promising therapeutic strategy in the management of coronary stenosis caused by KD. However, the long-term efficacy of a catheter intervention for KD is unclear. To verify these findings, more long-term follow-up studies are needed. Care should be paid to avoid acute coronary arterial complications and the development of new coronary aneurysms. Based on the successful of PTCA reported here, we recommend that the procedure should be considered early in subclinical stenosis to prevent ischemic cardiac damage.

1. Suzuki A,Kamiya T,Ono Y,Okuno M,Yagihara T. Aortocoronary bypass surgery for coronary arterial lesions resulting from Kawasaki diseaseJ PediatrYear: 19901165675732319403
2. Kitamura S. Surgical management for cardiovascular lesions in Kawasaki diseaseCardiol YoungYear: 19911240253
3. Kato H,Ichinose E,Yoshioka F,Yoshioka F,Takechi T,Matsunaga S,Suzuki K,Rikitake N. Fate of coronary aneurysms in Kawasaki disease: serial coronary angiography and long term follow up studyAm J CardiolYear: 198249175817667081062
4. Ino T,Akimoto K,Ohkubo M,Nishimoto K,Yabuta K,Takaya J,Yamaguchi H. Application of percutaneous transluminal coronary angioplasty to coronary arterial stenosis in Kawasaki diseaseCirculationYear: 199693170917158653877
5. Kato H,Akagi T,Sugimura T,Sato N,Kazue T,Hashino K,Nishiyori A,Sakaguchi M. Kawasaki diseaseCoron Artery DisYear: 199561942067788031
6. Kato H,Sugimura T,Akagi T,Sato N,Hashino K,Maeno Y,Kazue T,Eto G,Yamakawa R. Long-term consequences of Kawasaki disease: a 10 to 21 year follow-up study of 594 patientsCirculationYear: 199694137913858822996
7. Akagi T,Rose V,Benson LN,Newman A,Freedom RM. Outcome of coronary artery aneurysms after Kawasaki diseaseJ PediatrYear: 19921216896941432415
8. Checchia PA,Pahl E,Shaddy RE,Shulman ST. Cardiac transplantation for Kawasaki diseasePediatricsYear: 19971006956999310527
9. Kato H,Koike S,Yamamoto M,Ito U,Yano E. Coronary artery aneurysms in infants and young children with acute febrile mucocutaneous lymph node syndromeJ PediatrYear: 197586892898236368
10. Taubert KA,Rowly AH,Shulman ST. Seven-year national survey of Kawasaki disease and acute rheumatic feverPediatr Infect Dis JYear: 1994137047087970970
11. Sasaguri Y,Kato H. Regression of aneurysms in Kawasaki disease: a pathological studyJ PediatrYear: 19821002252317057330
12. Sugimura T,Kato H,Inoue O,Fukuda T,Sato N,Ishii M,Takagi J,Akagi T,Maeno Y,Kawano T,Takagishi T,Sasaguri Y. Intravascular ultrasound of coronary arteries in children: assessment of the wall morphology and the lumen after Kawasaki diseaseCirculationYear: 1994892582658281655
13. Akagi T,Kato H. Kawasaki diseaseBaillieress Clin PaediatrYear: 199644359
14. Detre K,Holubkov R,Kelsey S,Cowley M,Kent K,Williams D,Myler R,Faxon D,Holmes D,Bourassa M,Block P,Gosselin A,Bentivoglio L,Leatherman L,Dorros G,King S 3rd,Galichia J,al-Bassam M,Leon M,Robertson T,Passamani E. Percutaneous transluminal coronary angioplasty in 1985-1986 and 1977-1981N Engl J MedYear: 19883182652702961993
15. Hinohara T,Rowe MH,Robertson GC,Selmon MR,Braden L,Leggett JH,Vetter JW,Simpson JB. Effect of lesion characteristics on outcome of directional coronary atherectomyJ Am Coll CardiolYear: 199117111211202007710
16. Kitamura S,Kawachi K,Harima R,Sakakibara T,Hirose H,Kawashima Y. Surgery for coronary heart disease due to mucocutaneous lymph node syndrome (Kawasaki disease)Am J CardiolYear: 1983514444486600576
17. Kitamura S,Kawachi K,Seki T,Morita R,Nishii T,Mizuguchi K,Fukutomi M,Hamada Y,Iioka S. Bilateral internal mammary artery grafts for coronary artery grafts for coronary artery bypass operations in childrenJ Thorac Cardiovasc SurgYear: 1990997087152319795
18. Takeuchi Y,Suma K,Inoue K,Shiroma K,Koyama Y,Narumi J,Nishiyama S,Kaneko H,Kohri Y,Terada Y. The long-term result of grafted saphenous vein in the children with Kawasaki diseaseNippon Kyobu Geka Gakkai ZasshiYear: 19873554603494796
19. Ishii M,Ueno T,Akagi T,Baba K,Harada K,Hamaoka K,Kato H,Tsuda E,Uemura S,Saji T,Ogawa S,Echigo S,Yamaguchi T,Kato H. Guidelines for catheter intervention in coronary artery lesion in Kawasaki diseasePediatr IntYear: 20014355856211737728
20. Iemura M,Ishii M,Sugimura T,Kato H. Long-term consequences of regressed coronary aneurysms after Kawasaki disease: vascular wall morphology and functionHeartYear: 20008330731110677411

Article Categories:
  • Case Report

Keywords: Mucocutaneous lymph node syndrome (Kawasaki Disease), Percutaneous transluminal coronary angioplasty (PTCA).

Previous Document:  A case of primary plasmacytoma of lymph nodes.
Next Document:  Morphofunctional changes in the midgut of virgin tick females of the genus ixodes (Acarina: Ixodidae...