Coronary artery ectasia presenting as acute coronary syndrome and misinterpreted as coronary artery perforation: Case
Hongki Jeon1, Jin-Man Cho, In-Ho Yang
1Department of Internal Medicine, Division of Cardiology, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.
Insights
Coronary artery ectasia (CAE) with thrombotic occlusion presents challenges during percutaneous coronary intervention (PCI). Careful assessment with intravascular ultrasound and tailored strategies are crucial for successful treatment and optimal outcomes in CAE patients.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Coronary artery ectasia (CAE) can lead to thrombotic occlusion and acute coronary syndrome.
- Distal vessel morphology in CAE is unpredictable, complicating percutaneous coronary intervention (PCI).
Purpose of the Study:
- To describe a case of acute coronary syndrome due to coronary artery ectasia with total occlusion.
- To highlight the diagnostic and management challenges in such complex cases.
Main Methods:
- A 47-year-old male presented with acute coronary syndrome.
- Coronary angiography revealed diffuse CAE and total occlusion of the mid-left circumflex artery.
- Intravascular ultrasound-guided PCI was performed after initial thrombectomy and balloon angioplasty.
Main Results:
- Successful PCI was achieved in the ectatic culprit vessel.
- The patient remained stable with a patent stent at 9-month follow-up.
- No lesion progression was observed during follow-up.
Conclusions:
- Dye deposition in CAE can mimic vessel perforation, requiring caution during PCI.
- Intravascular ultrasound is essential for accurate lesion assessment in CAE.
- Individualized PCI strategies, including thrombectomy and glycoprotein IIb/IIIa inhibitors, are vital for managing high thrombus burden in CAE.
Rationale:
Coronary artery ectasia (CAE), characterized by diffuse dilation, can be associated with total thrombotic occlusion, leading to acute coronary syndrome. In such cases, distal vessel morphology can be highly unpredictable, potentially causing confusion during percutaneous coronary intervention (PCI).
Patient Concerns:
A 47-year-old man presented with sudden chest pain. Acute coronary syndrome was suspected based on symptom and elevated troponin I levels.
Diagnoses:
Coronary angiography revealed diffuse CAE and total occlusion of mid-left circumflex artery.
Interventions:
Due to the large thrombus, aspiration thrombectomy, intracoronary abciximab, and repeated balloon angioplasty were performed. After these procedures, there was absence of flow beyond the lesion, and huge extravasation around the vessel, resembling a coronary artery perforation. Considering various factors, we concluded it was not a perforation and subsequently performed intravascular ultrasound-guided PCI on the ectatic culprit vessel. After successful PCI, he was discharged on aspirin and clopidogrel. Due to heartburn, dual antiplatelet therapy was de-escalated to clopidogrel monotherapy after 6 months.
Outcomes:
During the follow-up, he remained stable, and a 9-month coronary angiography confirmed patent stent without lesion progression.
Lessons:
Stagnant flow in dilated vessels can cause local dye deposition, which may resemble procedure-induced perforation or dissection, necessitating heightened caution during PCI. Intravascular ultrasound is valuable for accurate assessment of lesions in CAE. Thrombectomy and glycoprotein IIb/IIIa inhibitors would be considered to manage high thrombus burden. Due to its diverse clinical presentations, CAE requires an individualized strategy, and can also be treated with simple PCI followed by dual antiplatelet therapy.
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