SWBJ

Percutaneous coronary intervention (PCI) for obstructive coronary diseasewith concurrent coronary artery ectasia (CAE) are often associated withuncertainties in view of the technical challenges. Our patient is a 52-year-oldsmoker with known hypertension and ischemic heart disease with previousintervention to the left anterior descending (LAD) artery in 2019, presentedwith a non ST segment myocardial infarction (NSTEMI). Initial ECG did not showany significant ST changes. 

Trans thoracic echocardiogram done during 2020 NSTEMI presentation showed apreserved left ventricular systolic function of 65% with no regional wallmotion abnormalities. He was subsequently brought to our invasive cardiac labfor coronary angiogram. 

Coronary angiogram showed patent stents in the proximal tomid LAD and otherwise normal right coronary artery (RCA). The mid to distal LCxappeared to be of large calibre (5-6mm) and ectactic. Severe stenosis was seenin the mid LCx with appearance of an ulcerative plaque. 

We switched to a XB 3.5 guiding catheter and wired to thedistal LCx. Intra-coronary eptifibatide was given and the lesion was preparedwith a 3.0 X 15mm Scoreflex balloon at 20 atm. In view of significant recoil,the lesion was further pre-dilated with a 4.0 X 15mm Scoreflex balloon at 20 atmwith satisfactory expansion and no recoil. In view of the large ectactic vessel,there were concerns about suboptimal stent placement and embolization. As therewas good expansion with no residual lesion after initial balloon angioplasty, adecision was made for an upfront drug eluting balloon (DEB) only strategy.We subsequently delivered a 4.0 X 35mm DEB at 8 atm for 45secondsto the mid LCx and achieved angiographic success with no complications ofdissection, distal embolization or no-reflow. Final images showed good balloonangioplasty results with TIMI 3 flow and less than 20% residual stenosis.A relook angiogram was offered during follow up in view ofthe balloon only strategy and unpredictability in coronary ectasia but patientdeclined. He subsequently presented again 1 year (2021) later fornon-cardiac chest pain and repeat coronary angiogram showed excellent DEBresult with minor residual stenosis and no significant recoil.

PCI strategies in acute coronary syndrome with concurrentCAE traditionally involves the use of stents and optimal stent landing andsizing can be difficult with risks of suboptimal stent deployment, migration or embolization. There is also increasedrisk of complications especially in tortuous vessels. Adequate lesionpreparation prior to definitive intervention strategy is of utmost importance. ADEB only approach is thus a possible alternative with the option of leavingnothing behind although further research is required to assess the long-termoutcomes and safety.