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).
Highlights
Coronary artery ectasia (CAE) often presents in the form of an acute coronary syndrome (ACS) due to slow flow leading to thrombus formation in ectatic coronary arteries, and getting rid of this high thrombus burden during the percutaneous coronary intervention (PCI) can be a challenging task
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 high clot burden was successfully dealt with using thrombectomy and a glycoprotein IIb/IIIa inhibitor followed by extended duration oral anticoagulation, avoiding intracoronary thrombolysis and negating the need for followup angiographies
Summary
Coronary artery ectasia (CAE) often presents in the form of an acute coronary syndrome (ACS) due to slow flow leading to thrombus formation in ectatic coronary arteries, and getting rid of this high thrombus burden during the percutaneous coronary intervention (PCI) can be a challenging task. For this purpose, thrombectomy with intracoronary thrombolysis has been utilized for restoring the blood flow. There have been cases showing migration of the clots into distal coronary vessels during thrombectomy attempts, making it difficult to establish immediate flow in all segments Such cases were managed with extended duration oral anticoagulation, and thrombus clearance was demonstrated with serial follow-up angiographies. The patient has been playing full-court basketball games without any further complaints or hospitalization
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