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Coronary Artery Ectasia-A Variant of Occlusive Coronary Arteriosclerosis

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Coronary Artery Ectasia-A Variant of Occlusive Coronary Arteriosclerosis British Heartjournal, 1978, 40, 393-400 Coronary artery ectasia-a variant of occlusive coronary arteriosclerosis R. H. SWANTON. M. LEA THOMAS, D. J. COLTART, B. S. JENKINS, M. M. WEBB-PEPLOE, AND B. T. WILLIAMS From the Departments of Cardiology, Radiology, and Cardiothoracic Surgery, St. Thomas' Hospital, London SUMMARY In a study of 1000 consecutive coronary arteriograms, 12 patients (all men) had coronary artery ectasia. Ectasia was found most frequently in the circumflex or right coronary artery. Only 1 patient had ectasia in the left anterior descending coronary artery. In 11 patients, ectasia ofone artery was associated with severe stenosis or occlusion of other vessels, typical of arteriosclerosis. Histology from an ectatic segment in one of this group showed changes of severe arteriosclerosis with extensive intimal fibrosis and destruction of the media. One patient had a mixed collagen vascular disease. Measurement of coronary sinus flow in 2 patients with coronary artery ectasia showed flows in the range of patients with non-ectatic coronary artery disease. At cardiac surgery flows down the grafts to ectatic arteries were in the same range as in grafts to non-ectatic vessels. Patients with coronary artery ectasia should be anticoagulated. Previous reports of pathological dilatation of the were measured in 2 of the 12 patients during coronary arteries have described the abnormal atrial pacing. A biopsy of an ectatic coronary artery dilatation as an aneurysm, whether saccular or was obtained at the time of cardiac surgery in 1 fusiform (Scott, 1948; Daoud et al., 1963; Befeler patient. et al., 1977). Since the dilatation may be diffuse and involve the majority of the artery, it is more Methods appropriate to describe the lesion as ectatic (Markis et al., 1976) rather than aneurysmal. Coronary arteriography was performed by the The incidence of coronary artery ectasia seems Judkins technique using a Siemens X Ray image remarkably constant. Daoud in a review of 694 intensifier system with a caesium iodide tube. The necropsies found an incidence of coronary artery arteriograms were recorded in at least 2 planes aneurysms of 1-4 per cent. Markis. et al. (1976) on 35 mm film at 50 frames/s. In addition, biplane in a series of 2457 coronary arteriograms showed 30 35 cm or 100 mm cut film were recorded. The patients with ectatic coronary arteries (1-2%). maximum coronary artery diameter assessed from Befeler et al. (1977) found 16 patients in a series of the arteriograms was measured using the methods 1246 coronary arteriograms (1.3%). of Vieweg et al. (1976). Early necropsy studies suggested that congenital Coronary sinus flow was measured in 2 cases aneurysms were the most common type, with using the method of Ganz et al. (1971) and was septic emboli also frequent (Scott 1948). More compared with coronary sinus flow in 14 patients recent work suggests that arteriosclerosis is the with non-ectatic coronary artery disease. A 7FG commonest aetiological factor, with destruction triple function thermodilution catheter (Wilton of the media the underlying cause (Markis et al., Webster Labs) was positioned in the coronary 1976). sinus via a left arm vein. Normal saline at room This paper reports on 12 patients found to have temperature was infuised via a Harvard 906 infusion coronary artery ectasia from a series of 1000 pump. The thermister outputs were fed through a consecutive patients undergoing coronary arterio- CBA-210 Wheatstone Bridge to a Phillips 7 graphy. Coronary sinus flow and lactate metabolism channel recorder. This technique of measuring coronary sinus flow primarily reflects left coronary Received for publication 10 October 1977 artery flow (Rayford et al., 1960) and depends on 393 394 R. H. Swanton, M. Lea Thomas, D. J. Coltart, B. S.Jenkins, M. M. Webb-Peploe, and B. T. Williams Table Clinical data Case No. Age (y) Sex Ex-smoker Symptoms FH Hypertension Lipids Previous infarct Additional conditions 1 49 M + AP - - N - Ulcerative colitis 2 50 M + AP - + Type IV - Cerebral emboli 3 37 M + AP,D + - Type lIa - - 4 51 M + AP - + N Anterior 5 71 M + D,AP syncope - - N _ MR (ant. chordal rupture) 6 56 M + AP,D - - Type IV Anterior PA myxoedema CVD 7 49 M + AP,D - - N Anterior Inferior 8 58 M + VT - - Type IV - PA 9 63 M + AP - - N Anterior MR (post. chordal rupture) 10 52 M + AP,D - - Type Ila Anterior 11 53 M - D + - N Anterior 12 48 M + AP - - Unknown Inferior Iliofemoral arteriomegaly AP, angina pectoris; D, dyspnoea; MR, mitral regurgitation; PA, pernicious anaemia; VT, ventricular tachycardia; CVD, collagen vascular disease; PH, family history of coronary artery disease; N, normal. good mixing of indicator (Bing et al., 1972) which mm * Ectatic arteries was infused at a high rate (48 to 50 ml/min) in 11 O Normal arteries these studies. Coronary sinus pacing was performed (Vieweg 1976) 0 at increments of 20 bpm from 80 or 100 bpm to 0 160 bpm or to the onset of chest pain. Left ventri- 10 cular and coronary sinus blood were sampled simultaneously at each pacing rate. The blood was 9. instantly deproteinised in 10 per cent perchloric acid, centrifuged, neutralised, and the lactate measured 8- with a Unicam SP 1800 spectrophotometer at 0 pH 7-2 using a tris-hydrazine buffer, NAD, and 0 . 7- 0 lactate dehydrogenase (Hohorst et al., 1959). 0 Abnormal lactatate metabolism was defined as extraction of less than 10 per cent of arterial 6 lactate (Cohen et al., 1966). 0 Results The clinical details of the patients are summarised 4 in the Table. All 12 patients were men aged between 37 and 71. Eleven had previously smoked more than 20 cigarettes daily. 3 Ten presented with angina, 1 with exertional dyspnoea, and 1 with paroxysmal dyspnoea caused 01 by ventricular tachycardia. Two had a family Total Circumflex LAD RigI ht history of coronary artery disease and two were Ectatic 6 1 6 hypertensive. Seven had had a myocardial infarct Stenosed or 5 10 5 before study, and 5 had hyperlipoproteinaemia occluded were Fredrickson on lipoprotein electrophoresis (2 Fig. 1 Maximal coronary artery diameter compared Type IIa and 3 were Type IV). Cases 5 and 9 had with Vieweg's data for normal coronary arteries. mitral regurgitation resulting from anterior and Distribution of ectasia primarily in circumflex and right posterior chordal rupture, respectively. Pernicious coronary artery with stenosed or occluded LAD anaemia was present in 2 cases, 1 of whom had a (left anterior descending). mixed collagen vascular disease. One patient (case 12) also presented with ischaemic symptoms in the right leg and translumbar aortography There was only 1 case of left anterior descending disclosed iliofemoral arteriomegaly (see Fig. 5). ectasia. Eleven patients had severe stenosis or Fig. 1 shows that ectasia was most commonly occlusion of non-ectatic vessels. One patient seen in the circumflex and right coronary arteries. (case 5) had an ectatic coronary artery with other Coronary artery ectasia 395 l Fig. 2 Typical examples of coronary artery ectasia. RAO, right anterior oblique view; LA T, lateral view. (A) Case 2, grossly ectatic circumflex system; (B) case 4, generalised ectasia in right coronary artery; (C) case 6, fusiform dilatation ofproximal circumflex in a man with collagen vascular disease. 396 H. R. Swanton, M. Lea Thomas, D.r. Coltart, B.S.7enkins, M. M. Webb-Peploe, and B. T. Williams vessels normal. Typical coronary arteriograms Medical Electronics 601D Cliniflow electromagnetic showing ectasia are shown in Fig. 2. flowmeter. Basal flows ranged from 30 to 150 ml/min The measurement of maximum coronary artery down grafts to arteries with areas of ectasia, and diameter from biplane cut-film angiograms is 22 to 115 ml/min down grafts to non-ectatic shown in Fig. 1, and is compared with the results vessels. of Vieweg's data for normal coronary arteriograms. The histology from an ectatic segment obtained A comparison of coronary sinus flow in 2 patients from case 2 at saphenous vein bypass grafting is with ectatic and 14 patients with non-ectatic shown in Fig. 4. The intima was grossly thickened coronary artery disease is shown in Fig. 3. In the and fibrotic. The media was extensively damaged, patients with non-ectatic coronary artery disease with destruction of both internal and external mean coronary sinus flow increased up to a heart elastic laninae. Cholesterol clefts occurred in giant rate of 140/min. At higher heart rates the mean flow cells in the intima. The appearances were typical did not increase. In the patients with ectasia, chest of severe arteriosclerotic disease. pain occurred at a heart rate of 80/min in 1, and in Four patients did not proceed to surgery. Case 6 the other flow did not increase over a heart rate of was diagnosed as having a collagen vascular disease 120/min, with chest pain occurring at 140/min. and treated with steroids. Case 8 had symptoms In both patients abnormal lactate metabolism occur- resulting from paroxysmal ventricular tachycardia red with the onset of angina. which was successfully controlled with drugs. Case Eight patients proceeded to cardiac surgery. 10 was lost to follow-up after cardiac catheterisation, Coronary artery bypass grafting was performed in and case 11 was considered unsuitable for operation 7, 1 of whom in addition had a mitral valve replace- because of very poor left ventricular function ment. One patient had a mitral valve replacement (ejection fraction 0 2). without additional coronary artery bypass grafting The 1 patient who was not improved by coronary (case 5). Graft flows were measured using a Carolina artery bypass grafting was restudied. The two grafts he had received were both occluded. All patients with coronary artery ectasia were 160 anticoagulated in the absence of contraindications.
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