Coronary Artery Ectasia: An Insight into Intraprocedural and Postprocedural Management Strategies

Abstract

Coronary artery ectasia (CAE) can present as an acute coronary syndrome (ACS) with a high clot burden in ectatic coronary arteries. Thrombectomy with intracoronary thrombolysis often does not ensure immediate blood flow. Also, there have not been clear guidelines regarding long-term management in such cases.A 40-year-old male presented with anginal chest discomfort and a working diagnosis of non-ST elevation myocardial infarction (NSTEMI) was made. The initial angiography showed thrombotic occlusion of several large and ectatic coronary arteries with visibly swirling blood flow. The culprit lesions were treated with balloon angioplasty and multiple rounds of thrombectomy yielding red thrombi. Interestingly, the post-intervention antegrade flow decreased in both vessels (Thrombolysis in Myocardial Infarction (TIMI) score: 0), possibly because of the distal migration of the clots. Peri-procedure, the patient received two boluses of eptifibatide, 180 mcg/kg each, followed by a continuous infusion of 2 mcg/kg/minute for 18 hours. Afterward, the patient was started on ticagrelor and continued on daily aspirin, high-intensity statin, beta blocker, and Coumadin® with heparin bridge. During the one year follow-up period, the Coumadin was switched to rivaroxaban, ticagrelor was stopped after six months, and the patient was continued on guideline-directed medical therapy (GDMT) for coronary artery disease (CAD) with favorable outcomes.The presented case gives us an insight into not only the intra-procedural but also the post-procedural management of ACS in the setting of CAE, and that is thrombectomy alone followed by longer duration oral anticoagulation in addition to GDMT for CAD. However, it will be interesting to see future studies aimed toward defining the duration as well as the choice of anticoagulation, i.e., dual antiplatelet therapy (DAPT) alone or in combination with warfarin/novel oral anticoagulants (NOACs).

Five-years’ prognostic analysis for coronary artery ectasia patients with coronary atherosclerosis: A retrospective cohort study

“…Third, the detailed treatment strategy for patients with CAE was explored in this study. From the perspective of MACE prevention, the progression of atherosclerotic lesions should be prevented in patients with CAE ( 23 , 24 ) while the anti-thrombotic treatments, are indicated for patients with CAE + AMI ( 25 , 26 ). As reported in our previous study, patients with CAE and CHD had minimal ectasia progression but the atherosclerosis progressed gradually ( 3 ).…”

Relation between Coronary Artery Ectasia Characteristics and Development of Acute Coronary Syndrome

“…Evidence suggests to a hereditary vulnerability, typical coronary artery disease risk factors, and abnormal vessel wall metabolism, even if the exact origin of its beginning is unknown (12) . CAE commonly presents as an ACS due to the slow flow that promotes thrombus buildup in CAE, and eliminating this considerable amount of thrombus with percutaneous coronary intervention (PCI) may be challenging (13) . According to certain coronary angiographic investigations, the prevalence of CAE is estimated to be between 3 and 5% (14) .…”

Antiagregantes y anticoagulantes en el manejo de ectasia coronaria con flujo lento, una revisión de reportes de caso

“…Al momento del diagnóstico se encontró en la angiografía y el ECG ectasia coronaria derecha e infarto del miocardio sin elevación del segmento ST, respectivamente. Posterior a la intervención angioplástica y trombectomía, se dio seguimiento al paciente con anticoagulantes orales: ácido acetilsalicílico más ticagrelor más Warfarina, este último suspendido a los 6 meses y se cambió Warfarina por rivaroxabán, con el que continúa actualmente, se siguió al paciente por un año, con resultados favorables y con el fin de evitar eventos cardíacos mayores en base a la evidencia ya presentada (Waqas et al 2019).…”