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Coronary Artery Ectasia: an Interventional Cardiologist’S Dilemma Matthew Schmidt and Timothy E Paterick*

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Coronary Artery Ectasia: an Interventional Cardiologist’S Dilemma Matthew Schmidt and Timothy E Paterick* ISSN: 2643-3966 Schmidt and Paterick. Int Arch Cardiovasc Dis 2018, 2:007 Volume 2 | Issue 1 Open Access International Archives of Cardiovascular Diseases CaSE REPoRT Coronary Artery Ectasia: An Interventional Cardiologist’s Dilemma Matthew Schmidt and Timothy E Paterick* Check for Bay Care Medical Group, Green Bay, Wisconsin, USA updates *Corresponding author: Timothy E Paterick, MD, JD. MBA, Bay Care Clinic, 4950 Founders Terrace, Hobart, Wisconsin 55145, USA, E-mail: [email protected] The term ‘ectasia’ refers to diffuse dilation of a cor- Abstract onary artery, while focal coronary dilation is called ‘a Coronary artery ectasia is defined as a localized, or diffuse coronary aneurysm’ [2]. The exact pathophysiology of dilation of a coronary artery lumen. Coronary artery ecta- sia is well recognized, but a rare finding encountered dur- CAE is unknown. CAE is an anatomical variant and a ing diagnostic coronary angiography. Coronary artery ec- phenotypic expression of coronary artery disease that tasia represents a form of atherosclerotic coronary artery may present with myocardial ischemia or coronary syn- disease, seen in 1.4-4.9% of patients undergoing coronary drome. The incidence varies between 1.2-4.9% [3]. The angiography. It may be an isolated finding, or in combination CASS registry found CAE in 4.9% of coronary angiograms with stenotic lesions. [3]. Our group classifies CAE as small (vessel size < 5 The classification of coronary artery ectasia is divided into mm), medium (vessels size 5-8 mm) and giant (vessel four groups: Type 1: Diffuse ectasia of two or three vessels, Type 2: Diffuse ectasia in one vessel and localized disease size > 8 m). CAE is defined as a coronary artery lumen in another vessel, Type 3: Diffuse ectasia in one vessel dilatation with a diameter of 1.5 times the adjacent nor- only, and Type 4: Localized or segmental involvement. mal coronary artery based on CASS registry [3]. This case illuminates the difficult decision making regarding Etiology stenting of coronary arteries with ectasia and atherosclero- sis. The additional challenge is whether the benefit of anti- The etiology of CAE can be enigmatic. Atherosclero- coagulation with warfarin outweighs the bleeding risk. The sis is considered the principal etiologic cause responsi- treatment approach is often ambiguous, and can be a vex- ble for greater than 50% of cases in adults, while Ka- ing clinical question, as identified in our case presentation. wasaki disease is the most common cause in children Keywords and young adults [4]. The histology of atherosclerosis Coronary artery ectasia, Coronary aneurysm, Thrombus, and ectasia are comparable. The mechanism of luminal Stenting, Anticoagulation dilation in some atherosclerotic vessels is ambiguous; atherosclerosis typically causes a narrowing of the ves- Introduction sel lumen. Luminal dilation due to arterial remodeling of certain plaques results in expansion of the media and Coronary artery ectasia (CAE) is defined as a local- external elastic membrane. This proposed methodology ized, or diffuse dilation of the coronary artery lumen of arterial remodeling may be operative in the case of exceeding the largest diameter of an adjacent normal CAE. coronary vessel by 1.5 fold. CAE is well recognized, but an uncommon finding encountered during diagnostic Intravascular ultrasound reveals that arterial remod- coronary angiography. The classification of CAE is divid- eling can be bidirectional depending upon expansion ed into four groups: Type 1: Diffuse ectasia of two or or contraction of the external elastic membrane. CAE three vessels, Type 2: Diffuse ectasia in one vessel and is believed to be exaggerated expansive remodeling localized disease in another vessel, Type 3: Diffuse ecta- of the external elastic membrane resulting in luminal sia in one vessel only, and Type 4: Localized or segmen- expansion. Enzymatic degradation of the extracellular tal involvement [1]. matrix-by-matrix metalloproteinases and other lytic en- Citation: Schmidt M, Paterick TE (2018) Coronary Artery Ectasia: An Interventional Cardiologist’s Di- lemma. Int Arch Cardiovasc Dis 2:007 Accepted: July 26, 2018; Published: July 28, 2018 Copyright: © 2018 Schmidt M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Schmidt and Paterick. Int Arch Cardiovasc Dis 2018, 2:007 • Page 1 of 5 • ISSN: 2643-3966 zymes and thinning of the tunica media associated with ing coronary artery disease is a malicious combination severe chronic inflammation is considered the principal with an increased potential for adverse cardiac events. pathogenesis of the expansive remodeling [5]. CAE is Isolated CAE still carries the risk of myocardial ischemia also related to apical HCM with high wall tension. For- and infarction. Type 1 and Type 2 CAE carry a higher risk mation of aneurysms may be seen post percutaneous than Type 3 and Type 4 CAE. There is no reported data coronary interventions including balloon angioplasty, showing a relationship between the diameter of an ar- stent placement, and atherectomy. The mechanism is tery and outcome [9]. felt to be injury of the media of the blood vessel [6]. Treatment Diagnosis Management of CAE is fraught with uncertainty be- Coronary angiography is the gold standard in diag- cause the rarity of CAE prevents large randomized trials nosing CAE. Intravascular ultrasound (IVUS) is critical to comparing different treatment approaches. When CAD the evaluation of luminal characteristics and patholo- coexists intense primary and secondary risk factor mod- gies [6]. Distortions in coronary flow and washout are ifications is mandatory. common in CAE and are related to the severity of ecta- Management of isolated CAE in the case with an- sia. Signs of stagnant flow include: Delayed antegrade gina or myocardial ischemia includes ASA, statin, and contrast filling, segmental back flow, and stasis in the anti-ischemic medications. Acute coronary syndromes ectatic coronary segment 5[ ]. associated with CAE may require thrombolysis, heparin Clinical Significance administration and glycoprotein 2b/3a receptor inhib- itors. Thrombus aspiration may be needed during pri- Symptoms may be associated with concomitant cor- mary PCI. Percutaneous and surgical interventions are onary disease, Kawasaki disease, or connective tissue often needed in patients with CAE and stenotic lesions disease. Most patients are asymptomatic. Patients with where angina persists despite maximal medical therapy. CAE may present with angina, positive stress tests, and Optimal stent sizing, misplacement, and embolization acute coronary syndrome. Diminished coronary flow, or of stents, early stent thrombosis, and restenosis haunt stagnancy of blood flow, may cause exercise-induced an- stenting procedures [10,11]. gina without coexistent stenotic coronary artery disease. Formation of intracoronary thrombus and dissipation of Long-term anticoagulation is a debated topic with emboli distally may be the trigger of the acute coronary no randomized trials to confer benefit. The antiplatelet syndrome, which is hastened by stagnant flow in the ec- benefit must be weighed against the risk of hemorrhage. tatic coronary segment. CAE is predisposed to vasospasm, which may elicit angina, or acute coronary syndrome. In Case people less than 50 years CAE should raise a concern for 51-year-old African American male presented to the connective tissue disorders and vasculitides [7,8]. emergency room with chest pain. He was found to have Prognosis an elevated troponin. The blood troponin level was 0.45 (< 0.05) and rose to 2.6 His ECG was abnormal. (Figure Prognosis for CAE is directly related to the severity of 1) The ECG was unchanged from the one recorded in concomitant coronary artery disease. CAE with underly- 2014. Figure 1: Sinus rhythm, left axis, and inverted t waves 1, 2 aVL, V 3-6. Schmidt and Paterick. Int Arch Cardiovasc Dis 2018, 2:007 • Page 2 of 5 • ISSN: 2643-3966 Figure 2: a) Coronary angiogram LAO view revealing occluded proximal LAD (2014); b) Coronary angiogram RAO post thrombectomy and placement of a 4.0*22 resolute stent (2014). Figure 5: The Parasternal Long axis of the LV revealing a 17 mm septum in a patient with HCM. ing coronary artery (LAD). He underwent thrombecto- my and proximal LAD stenting (Figure 2a and Figure 2b). Figure 3: Ectatic right coronary artery. During angiography Type 1 CAE was identified. The right coronary artery (RCA), Circumflex coronary artery (Cf) and LAD were all large luminal vessels consistent with coronary artery ectasia. (Figure 3 and Figure 4) The patient had a symptomatic episode of ventricular tachycardia that was hemodynamically compromising and was managed with cardioversion. The patient re- covered and was treated with ASA and ticagrelor for 18 months and then changed to just ASA. He remained ac- tive and free of cardiovascular symptoms. Past Medical History: The patient has a history of gene-negative hypertrophic cardiomyopathy (HCM). In 1983 at age 16 years he had a syncopal episode while playing basketball and was identified to have HCM by echocardiography (Figure 5, Figure 6, Figure 7 and Fig- Figure 4: Ectatic circumflex coronary artery (Blue arrows). ure 8). In 2002 the patient had another syncopal episode was found to have non-sustained ventricular tachycar- Four years previously the patient had experienced dia on Holter monitoring. He had an ICD placed. He had an acute occlusion of his proximal left anterior descend- hypertension, coronary artery disease, HCM, hyperlipid- Schmidt and Paterick. Int Arch Cardiovasc Dis 2018, 2:007 • Page 3 of 5 • ISSN: 2643-3966 Figure 6: Apical 4 chamber view of the LV showing small LV cavity. Figure 9: Ectatic RCA. Figure 7: Apical 4 chamber view of the LV showing the end systolic dimension with LV cavity obliteration. Figure 10: Circumflex Thrombus: red outline 2018. Physical Examination: Reveals a well developed black male with a blood pressure 130/70 mmHg and pulse of 48 bpm.
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