A 32-year-old man was admitted to emergency department of Chonnam National University Hospital for severe chest pain. He had suffered from new onset severe angina for 5 hours. It was a heaviness nature and relieved by sublingual nitroglycerin. He did not have specific cardiovascular risk factors. Twelve-lead electrocardiogram showed normal sinus rhythm without ST-segment change or T-wave inversion. However, the level of cardiac enzyme was elevated (high-sensitivity troponin-T 0.921 ng/ml [reference range 0-0.1]) and transthoracic echocardiogram showed preserved left ventricular systolic function (left ventricular ejection fraction was 55%) with akinesia of anterior wall. Coronary angiography (CAG) revealed large filling defect in middle left anterior descending artery (LAD) with coronary ectasia and turbulent flow at distal part of the filling defect, and thrombotic total occlusion in diagonal branch (Figure 1). After intracoronary abciximab injection with several times of thrombi aspiration, large amount of red thrombi was aspirated (Figure 2). Then, we examined optical coherence tomography (OCT) for further evaluation, and it revealed large amount of red thrombi without definite atheromatous plaque (Figure 3). We performed thrombi aspiration again several times, and follow-up CAG showed distal embolization of thrombi, but decreased thrombotic burden (Figure 4). Then, we finished the procedure and decided to do follow-up angiography after intensive medical treatment including aspirin, prasugrel and heparin. We took his medical history more specifically. He denied any drug abuse and did not have infectious disease history such as Kawasaki disease or syphilis.
After one week, follow-up CAG showed marked resolution of filling defect in distal LAD, diagonal branch, and middle LAD (Figure 5). Follow up OCT also showed marked reduction of intracoronary thrombi (Figure 6). We did not deploy any stents for this lesion because there was no definite plaque burden. The triple therapy was continued using aspirin, prasugrel, and warfarin. He did not complain further chest pain and discharged without any cardiovascular events at the 11th hospital day.
Coronary artery ectasia is dilatation of an arterial segment to a diameter at least 1.5 times that of the adjacent normal coronary artery. It can be found in 3-8% of angiographic and in 0.22-1.4% of autopsy series. Some cases of coronary artery are ectasia associated with inflammatory or connective tissue diseases such as syphilitic aortitis, Kawasaki disease, scleroderma, and Ehlers-Danlos syndrome. The aneurysmal segments produce turbulent blood flow, and it increased incidence of typical effort angina and myocardial infarction regardless of existing stenotic lesions. Most patients with pure ectasia have a benign course, but 39% still present myocardial infarction. Previous studies based on the significant flow disturbances within the ectatic segments, suggested chronic anticoagulation as main therapy. However, this treatment has not been prospectively tested, and cannot be recommended unless supported by subsequent studies. When coexisting with coronary artery disease, the treatment of coronary artery ectasia is the same as for coronary artery disease alone. In isolated coronary artery ectasia, anti-platelet drugs are the mainstay of treatment.
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Figure 1. Coronary angiography showed no significant stenosis in right coronary artery (A), but there was large thrombotic filling defect in middle left anterior descending artery (arrow) with coronary ectasia and total occlusion in diagonal branch (arrow head) (B, C, and D)
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Figure 2. After intracoronary abxicimab injection, thrombus aspiration was done for target lesion several times
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Figure 3. Optical coherence tomography revealed large amount of red thrombi without fixed stenosis
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Figure 4. Follow-up angiography showed distal embolization of thrombi (arrow), but decreased thrombotic burden
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Figure 5. After one week, follow-up coronary angiography showed marked resolution of filling defect in target lesion and diagonal branch
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Figure 6. Follow-up optical coherence tomography showed marked reduction of intracoronary thrombi
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