Key result
In a 40-year-old male with coronary artery ectasia presenting as NSTEMI, mechanical thrombectomy followed by extended oral anticoagulation resulted in favorable outcomes at one year.
Why the study?
Coronary artery ectasia presenting with high clot burden often fails to achieve immediate blood flow with standard procedures, and clear guidelines regarding long-term management are lacking.
Case Report (n=1)
No
In a patient with NSTEMI and coronary artery ectasia, mechanical thrombectomy followed by extended oral anticoagulation and GDMT resulted in favorable long-term outcomes without the need for intracoronary thrombolysis.
Supports anticoagulation and antiplatelet therapy in coronary ectasia post-intervention; extends sparse randomized evidence for this rare condition.
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).
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Waqas et al. (2019) conducted a case report in Coronary Artery Ectasia presenting as NSTEMI (n=1). Thrombectomy and extended oral anticoagulation was evaluated on Clinical outcome at 1 year. In a 40-year-old male with coronary artery ectasia presenting as NSTEMI, mechanical thrombectomy followed by extended oral anticoagulation resulted in favorable outcomes at one year.
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