Coronary Artery Ectasia in Atherosclerotic Coronary Artery Disease, Inflammatory Disorders, and Sickle Cell Disease

Abstract

SUMMARYCoronary artery ectasia (CAE) or aneurysm is usually defined as dilation ≥1.5-fold the normal vessel diameter. It has an incidence of 1.4-5.3% and is associated with a wide variety of etiologies-mainly congenital, atherosclerotic, and inflammatory ones. CAE is very common in sickle cell disease, and possibly sickle cell trait, with an incidence of 17.7%. It is likely related to the inflammatory process associated with hemoglobin S. Prognosis depends mainly on the underlying etiology. Atherosclerotic CAE does not carry additional risks compared to atherosclerotic coronary artery disease (ACAD) without ectasia. However, isolated CAE in the absence of ACAD carries an increased risk of myocardial infarction (MI) due to vasospasm, slower coronary blood flow, and thrombosis, typically within the dilated segments. Due to lack of studies and guidelines, management recommendations are based on personal experiences. Therapy should be tailored to each individual case after assessment of severity, history of complications, underlying etiology, and comorbidities. Treatment of underlying condition and avoidance of exacerbating factors are essential. Medical therapy in general may include antiplatelets, b-blockers, angiotensin-converting enzyme inhibitors statins, and dihydropyridine calcium channel blockers. In severe CAE or history of MI, the addition of anticoagulation therapy after assessing bleeding risk may be warranted. In acute MI, the large thrombus burden in the dilated segment makes the percutaneous approach very challenging. Aspiration attempts can result in distal thromboembolization. Survival is better in bypass grafting than with medical therapy. Nonetheless, bypass grafting does not improve survival in atherosclerotic CAE. Depending on the physical characteristics of aneurysm, different surgical approaches can be sought; however, the ideal one is unclear.

Matrix Metalloproteinases and Coronary Artery Ectasia.

“…Epidemiological data extrapolated from different studies allow us to calculate a prevalence of CAE between 1.4% and 7.4% of patients undergoing coronary angiography [2,7] with a higher prevalence in the men, in according to our study [8,9]. The average age, furthermore, was comparable, at the time of diagnosis, both in the cases and in the controls.…”

ST-Segment Elevation Myocardial Infarction as a Result of Coronary Artery Ectasia-Related Intracoronary Thrombus in a Patient with Liver Cirrhosis

“…Several conditions, like inflammation, trauma, connective tissue disorders, infections, and the use of certain drugs, lead to this type of ectasia. [9] The atherosclerotic type has been reported to be associated with risk factors such as male sex, hypertension, diabetes mellitus, dyslipidemia, history of stroke, and cigarette smoking, which are similar to those of CAD in general. [1,3,9] CAE is often related to endothelial damage and microvascular dysfunction, and dilation of a coronary segment tends to result in stasis, delayed antegrade filling, and segmental back flow.…”

“…[9] The atherosclerotic type has been reported to be associated with risk factors such as male sex, hypertension, diabetes mellitus, dyslipidemia, history of stroke, and cigarette smoking, which are similar to those of CAD in general. [1,3,9] CAE is often related to endothelial damage and microvascular dysfunction, and dilation of a coronary segment tends to result in stasis, delayed antegrade filling, and segmental back flow. Such conditions cause various manifestations, such as sluggish and turbulent blood flow, coronary vasospasm, spontaneous dissection, or thrombus formation, and these mechanisms can contribute to diverse clinical syndromes.…”

“…[9] Although anticoagulation therapy is important for preventing the recurrence of myocardial infarction in the current case, we decided to use dual-antiplatelet therapy with aspirin and ticagrelor, a potent new P2Y 12 inhibitor, considering his mean INR of about 2.0 [15]. Treatment varies depending on the type of CAE, except for antiplatelet and anticoagulation therapies.…”

Thiol/disulfide homeostasis: A new insight into coronary artery ectasia

“…There is no consensus about the etiology, prognostic significance, and morbidity related to this condition. There are three main types of CAE: [3].…”