Diffuse Pericoronary Soft-Tissue Cuffing on Coronary Computed Tomography Angiography in a Patient with Unstable Angina: Possible IgG4-Related Coronary Periarteritis

Figures

• 

  Figure 1. The patient reported intermittent precordial discomfort for four days, worsening over the 10 h before presentation and relieved by nitroglycerin. Blood pressure was 130/80 mmHg and heart rate 71 beats/min; the electrocardiogram showed sinus rhythm with ST-segment/T-wave changes. Cardiac troponin was not available; the working diagnosis of unstable angina was therefore clinical, and non-ST-segment elevation myocardial infarction was not excluded. Cardiovascular risk factors included hypertension for more than 10 years, type 2 diabetes mellitus for more than 3 years, a 50-year smoking history (quit 1 year earlier), and a prior gastric ulcer. No evaluation for extra-coronary organ involvement of IgG4-related disease (salivary and lacrimal glands, pancreas, biliary tree, kidneys, retroperitoneum, aorta, lymph nodes) was documented; because isolated single-organ coronary involvement is uncommon in IgG4-related disease, this absence lowers the pre-test probability of the systemic diagnosis [1]. Coronary computed tomography angiography (CCTA) with axial images (A,B), cinematic volume-rendered reconstruction (C), and curved planar reconstructions (D–F) in a 66-year-old man presenting…

• 

  Figure 2. CCTA demonstrated a right-dominant coronary circulation with atherosclerotic involvement of all three epicardial territories; obstructive stenosis was confined to the proximal left circumflex artery, corresponding to CAD-RADS 2.0 category 4B [2], whereas disease in the left anterior descending and right coronary arteries was non-obstructive. More strikingly, there was diffuse soft-tissue attenuation surrounding the major epicardial coronary arteries, whose irregular outer wall contour imparted a sheath-like configuration. On the axial image at the level of the left main bifurcation (Figure 1A), calcific foci lay embedded in soft-tissue attenuation cuffing the proximal left coronary segments. The axial image at the proximal right coronary artery (Figure 1B) showed the contrast-filled vessel enveloped by a near-circumferential halo of soft tissue within the right atrioventricular groove fat. The cinematic volume-rendered overview (Figure 1C) displayed the global distribution of the epicardial coronary tree and its spatial relationship to the aortic root and cardiac silhouette; as a thresholded surface display, it omits the pericoronary soft-tissue component. Curved planar…