|Year : 2018 | Volume
| Issue : 2 | Page : 143-147
The multimodal use of thrombo-aspiration catheter during primary angioplasty using pharmaco-invasive strategy in coronary artery ectasia
Pankaj Jariwala1, Edla Arjun Padma Kumar1, Ajay Reddy2
1 Department of Cardiology, Maxcure-Mediciti Hospitals, Hyderabad, Telangana, India
2 Indira Nursing Home, Hyderabad, Telangana, India
|Date of Web Publication||13-Dec-2018|
Dr. Pankaj Jariwala
Maxcure-Mediciti Hospitals, Opposite Secretariat, Hyderabad, Telangana, 500063
Source of Support: None, Conflict of Interest: None
Coronary artery ectasia is a unique form of the coronary artery disease, which when encountered poses therapeutic dilemma and difficulties in the management. The diffuse dilatation of coronary arteries involving more than two adjacent coronary segments commonly presents as acute coronary syndrome secondary to thrombotic and ischemic manifestations. Usually, primary angioplasty in the setting of coronary artery ectasia is a challenging task for interventional cardiologists as the entry of guide wire across the lesion secondary to slow flow, dilated segments, and large thrombus burden. Further, high chances of the no-reflow phenomenon and distal embolization of thrombus are additional challenges while performing primary angioplasty in the setting of coronary artery ectasia. We combined pharmacological method such as the injection of intracoronary tenecteplase and invasive approach using thrombo-aspiration catheter for visualization of mid- and distal segments of the vessel, the passage of guide wire, and dethrombosis. The novel therapeutic uses of thrombo-aspiration catheter included working as a multidomain technique for intracoronary delivery of drugs like perfusion balloon, injection of contrast like guide catheter, the passage of guide wire through stenosis like micro-catheter, and finally, as thrombo-aspiration as in the present case.
Keywords: Acute myocardial infarction, coronary ectasia, primary angioplasty, thrombo-aspiration
|How to cite this article:|
Jariwala P, Padma Kumar EA, Reddy A. The multimodal use of thrombo-aspiration catheter during primary angioplasty using pharmaco-invasive strategy in coronary artery ectasia. Indian Heart J Interv 2018;1:143-7
|How to cite this URL:|
Jariwala P, Padma Kumar EA, Reddy A. The multimodal use of thrombo-aspiration catheter during primary angioplasty using pharmaco-invasive strategy in coronary artery ectasia. Indian Heart J Interv [serial online] 2018 [cited 2019 Mar 25];1:143-7. Available from: http://www.ihji.org/text.asp?2018/1/2/143/247455
| Introduction|| |
Coronary artery ectasia (CAE) is an incidental finding during coronary angiography, and there is a diffuse dilatation of coronary artery of more than 1.5-fold of single or more vessels. Localized abnormal dilatation of vessel is called coronary artery aneurysm. However, there are no strict definitions available to differentiate these conditions, and they may overlap in their presentations. We do not have proper guidelines or randomized controlled trials for their management. Our experience is based on a few anecdotal case reports and small case series published in the literature. We report a case of acute anterior wall myocardial infarction with diffuse ectasia of the left anterior descending coronary artery. We used a “multistrategy sequential pharmaco-invasive approach” for dethrombosis and revascularization of an ectatic left anterior descending artery (LAD).
| Case Report|| |
A 38-year-old male presented at the emergency room with complaints of discomfort due to a retrosternal burning in the chest for the past 2h. He was a cigarette smoker and tobacco chewer for the past 8 years. His vital parameters showed a pulse rate of 78 beats/min and a blood pressure of 130/80 mmHg. On examination, there were no signs of heart failure and lungs were clear. The electrocardiogram (ECG) showed ST-segment elevation in leads V2–V6 and II, III, and aVF [Figure 1]A. Echocardiography revealed hypokinesia of distal inter-ventricular septum, apex, apical, and mid-anterior segments with ejection fraction of 50%. In view of the ongoing chest pain, the patient was shifted to the cath lab for primary angioplasty. The patient was given a loading dose of aspirin 325mg, clopidogrel 300mg, and atorvastatin 80mg before shifting to the cath lab. Transradial coronary angiography revealed occlusion of the midsegment of the ectatic left anterior descending coronary artery [Figure 2]A and B]. Other vessels did not show any significant lesions. We had a dilemma in performing primary coronary intervention (PCI) as there could have been a large thrombus occluding midsegment of LAD. Hence we decided on the pharmaco-invasive strategy. We injected 10mg of tenecteplase using 6 Fr. Export thrombo-aspiration catheter was placed in the occluded segment over the guide wire. After 15min of the waiting period, contrast injection done through thrombo-aspiration catheter showed the course of the LAD beyond the occluded segment. We advanced the guide wire and thrombo-aspiration catheter assembly further till the visualized segment of LAD. Injection of contrast again through thrombo-aspiration catheter showed critical stenosis of distal LAD segment with thrombus. The distal LAD flow could be traced up to an apical segment of LAD with TIMI 2 flow. The guide wire could cross the stenotic segment with the support of thrombo-aspiration catheter [[Figure 3]A–F]. The thrombo-aspiration catheter advanced further to aspirate the thrombus. The angiography was checked after thrombo-aspiration demonstrated TIMI 3 flow in LAD with the residual lesion. An everolimus eluting stent (3.0×24mm) was deployed. The proximal segment of the stent was post dilated using a 4.0×10mm noncompliant balloon (Proximal optimization technique) [[Figure 4]A–F]. Post stenting, there was sluggish flow (TIMI II) and hence intracoronary sodium nitroprusside was given which improved flow to TIMI III [[Figure 5]A and B]. The patient had a reduction of chest discomfort and post-procedure ECG showed complete resolution ST-segment elevation [[Figure 1]B. The patient was discharged post-procedure on dual antiplatelet therapy, calcium channel blocker, ramipril, and high-intensity statin therapy.
|Figure 1: Electrocardiograph in emergency room (A) showed ST segment elevation in leads V2–V6, II, III, and aVF. Post procedure (B), there was ST-segment resolution with T-wave inversion in leads V1–V6, II, III, and aVF|
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|Figure 2: Coronary angiography of right coronary artery showed nonobstructive coronary artery disease (A) while that of the left coronary system revealed mid segment thrombotic total occlusion of the ectatic left anterior descending artery (B). There was diffuse coronary artery ectasia of LAD starting from the ostioproximal segment extending to the midsegment whereas left circumflex artery was normal|
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|Figure 3: During primary angioplasty, there was difficulty in the passage of guide wire (A). Hence, over the wire, thrombo-aspiration catheter was passed up to the occluded segment (B). Intracoronary tenecteplase injected through it. The contrast injection through thrombo-aspiration catheter could visualize the distal segment (C). The guide wire crossed with the support of thrombo-aspiration catheter into distal LAD (D) and further, thrombo-aspiration performed using it (E). Post thrombo-aspiration, there was residual stenosis of the distal segment of the left anterior descending artery with the disparity in the diameter (F)|
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|Figure 4: After thrombo-aspiration, there was residual stenosis (A, B), hence, 3.0×20mm everolimus-eluting stent was deployed across the lesion (C). The proximal segment of stent post dilated using 4.0×10mm noncompliant balloon (proximal optimization technique) (D). Intracoronary sodium nitroprusside was injected to tackle slow flow phenomenon (E). Final angiography showed brisk TIMI III flow without any residual stenosis (F)|
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|Figure 5: Final coronary angiography (right anterior oblique caudal view) in early (A) and late (B) phases, as there was “slow-flow phenomenon” secondary to coronary artery ectasia. There was no residual stenosis with TIMI III flow in the left anterior descending artery|
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| Discussion|| |
CAE is secondary to diffuse and systemic process that leads to involvement of more than two adjacent coronary segments or at least 50% involvement of length of the coronary artery., CAE is an uncommon finding during coronary angiography. CAE could be atherosclerotic or non-atherosclerotic in etiology. Ipek et al. showed a strong association of hypertension and smoking in a patient with CAE undergoing primary angioplasty. In our case, heavy use of tobacco-related products by the patient could be responsible for the development of CAE in early age. Approximately 50% of the coronary ectasia cases have been related to coronary atherosclerosis, whereas other possible etiologies include congenital abnormalities, inflammatory diseases like Kawasaki disease, and connective tissue disorders. Patients with CAE have polymorphism of the metalloproteinase-3 (MMP-3) which leads to its overactivity. This leads to increased vessel wall degradation of various matrix proteins, such as proteoglycans, laminin, fibronectin, and collagens.
Campanile et al. reviewed the patients of primary angioplasty in eight Italian centers, of whom 1.7% had coronary ectasia. The procedural success was recorded in 70% of cases. They studied the composite primary endpoint of cardiac death, recurrence of acute myocardial infarction, and a new revascularization at 2 years. There were 6.9% of cases during hospitalization, 17.8% at 1 year, and 38.5% at 2 years. Ipek et al. evaluated 1655 patients (99 patients in CAE group vs. 1556 patients in control group) undergoing primary angioplasty, and in their study, there were no significant differences in in-hospital mortality, revascularization rate, and one-year mortality rate.
Acute coronary syndrome secondary to thrombus formation with distal embolization is a common presentation of CAE. Ectatic coronary arteries have impaired coronary blood flow with antegrade slow flow along with stasis, backflow called as milking phenomenon, and endothelial and microvascular dysfunction.,
Non-atherosclerotic CAE has a better prognosis compared with atherosclerotic CAE though they have similar long-term prognosis as compared to atherosclerotic non-CAE. Markis et al. proposed a classification of CAE based on the extent of ectatic involvement. In decreasing order of severity, diffuse ectasia of two or three vessels was classified as type I, a diffuse disease in one vessel and localized disease in another vessel as type II, diffuse ectasia of one vessel only as type III, and localized or segmental ectasia as type IV. The proximal and midsegments of the right coronary artery are the most frequently involved, followed by the left anterior descending artery and the circumflex artery.
There are no guidelines or consensus for the management of ACS in the setting of CAE. The rate of no-reflow phenomenon is higher during primary angioplasty in CAE group in the study by Ipek et al. Also there are higher chances of thrombus embolization into distal circulation, and hence, effective sequential dethrombosis strategies using different pharmacological and mechanical methods are needed. A multidisciplinary pharmaco-invasive approach such as the use of drugs such as intracoronary thrombolytic agents, heparin, GP IIb/IIIa inhibitors along with mechanical strategies such as the use of thrombo-aspiration catheter is needed for the dethrombosis in cases with massive thrombus. The placement of the stent is controversial but if with the advent of newer generation drug-eluting stents, which can be expanded, to match the diameter of ectatic coronary arteries can be used avoiding carefully aneurysmal areas like in our case.
Optical coherence tomography (OCT) is more accurate as it has better resolution than intravascular ultrasound (IVUS) for the evaluation and characterization of plaque features in acute coronary artery disease. In most cases of CAE, OCT is not feasible as affected vessels are of large diameter. IVUS could differentiate the pathophysiology of acute myocardial infarction in the setting of CAE caused by spontaneous thrombosis without coronary plaque or plaque rupture secondary to intimal inflammation or coronary embolism. We did not perform IVUS because of financial constraints.
Lee et al. used intracoronary alteplase to lyse the thrombotic burden in an ectatic right coronary artery using micro-catheter. Kelly et al. demonstrated the use of intracoronary thrombolysis in the setting of acute myocardial infarction using tenecteplase in 34 patients, and only 1 patient had major bleeding. Also Boscarelli et al. demonstrated establishment of ≥TIMI 2 flow using intracoronary thrombolysis with the help of alteplase (73%) and tenectaplase (27%) in 30 patients with massive thrombus. No patient had major bleeding, and 82% patients had more than 50% ST segment resolution. In recent years, intracoronary thrombolysis has been increasingly used as an adjuvant therapy for primary PCI, as different studies using different thrombolytic agents have shown it to be safe and effective.
The medical management of these cases depends on the pathophysiology of coronary ectasia and needs to address the systemic diseases associated with it. The standard secondary prevention therapy remains the same as in any patient without CAE. The role of oral anticoagulation is controversial because of the risk of increased incidence of bleeding. Dual antiplatelet therapy is sufficient for post-angioplasty. Other supportive treatments in the form of ACE inhibitors, beta-blockers, dihydropydine calcium channel blockers, and statins are needed for the long-term management.
| Conclusion|| |
CAE during primary angioplasty is uncommon but when encountered, needs a different treatment strategy as compared with the routine case. However, for ectatic coronary arteries, because the amount of thrombus is massive and blood flow is slow, no single strategy would be sufficient. The combined multidisciplinary sequential dethrombosis strategy with the help of different pharmacological and mechanical invasive approaches is needed for the successful revascularization of these patients. The novel multimodality use of thrombo-aspiration catheter helps in dethrombosis of massive thrombus in the setting of CAE. Also the use of intracoronary thrombolytic agent is safe and a useful adjunctive therapy for revascularization of occluded ectatic coronary arteries in the setting of acute myocardial infarction but warrants further need of larger randomized controlled studies to demonstrate its efficacy to be used as a routine clinical practice.
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