Overview
Separation of the intima-media from the coronary artery wall due to tearing of the coronary artery intima-media or intracoronary hemorrhage can result in severe chest pain, nausea and vomiting, sweating, and dyspnea, depending on the severity of the disease. Spontaneous coronary artery entrapment has not yet been fully defined, and secondary coronary artery entrapment has been associated with percutaneous coronary interventions. Most patients with coronary artery entrapment have a favorable prognosis with prompt treatment, but some cases may result in death
Definition
A coronary artery is a blood vessel that supplies blood to the heart. When the coronary artery lining is torn by various factors, or when a trophoblastic vessel within the coronary artery wall ruptures and bleeds, blood flows through the tear into the coronary artery wall between the lining and the intima and separates the two, creating a false lumen that compresses the coronary artery and makes the lumen smaller, this is known as a coronary artery entrapment.
Staging
Clinical classification is usually based on the cause of the disease, the morphologic characteristics of the entrapment, and the severity of the entrapment.
Classification according to etiology
Primary coronary artery entrapment
It is a rare coronary artery disease in which the inner lining of the coronary artery spontaneously tears and forms a hematoma sandwich due to various physiologic and pathologic factors without the intervention of external factors such as surgery or trauma.
The main cause of coronary atherosclerosis, non-medical, non-coronary atherosclerotic coronary artery entrapment is also known as spontaneous coronary artery entrapment.
Secondary coronary artery entrapment
Coronary artery entrapment is usually caused by medically induced injury resulting from invasive treatment, such as a common postoperative complication of percutaneous transluminal coronary angioplasty (PTCA).
In addition, the etiology of primary coronary artery entrapment has not yet been fully clarified, and some cases of coronary artery entrapment with unknown causes are usually referred to as idiopathic coronary artery entrapment in clinical practice [1].
Classification according to morphological characteristics and severity of the entrapment
Currently, according to the criteria of the National Heart, Lung, and Blood Institute (NHLBI), there are 6 types of coronary artery entrapment (A-F), which are classified according to the results of the imaging examinations, and the purpose is to evaluate the prognosis of coronary artery entrapment and to provide a basis for the therapeutic process.
Type A: A few translucent images of intimal tears in the lumen, little or no contrast retention, and zero incidence of acute occlusion.
Type B: 2 parallel lumens separated by fluoroscopy, little or no contrast retention, 3% incidence of acute occlusion.
Type C: contrast retention outside the coronary artery lumen, 10% incidence of acute occlusion.
Type D: coronary artery lumen with a spiral contrast-filled defect, acute occlusion rate of 30%.
Type E: intimal tear with persistent contrast filling defect, acute occlusion rate 9%.
Type F: intimal tear with complete coronary artery occlusion, acute occlusion incidence 69%.
Among them, types A and B2 are mild entrapment, which usually do not lead to ischemic complications and can be left untreated depending on the situation; types C-F are severe entrapment, which can lead to serious outcomes such as acute myocardial infarction or even death if not treated in time [2].
Morbidity
The incidence of primary coronary artery entrapment is low, but the morbidity and mortality rates are relatively high. One study showed that 69% of primary coronary artery entrapment cases were seen at autopsy, and the detection rate of coronary angiography was only 0.1%.
Spontaneous coronary artery entrapment occurs in women, accounting for 81% to 92% of all cases, and is particularly common in pregnant women. Patients are usually between 45 and 53 years of age, and perinatal women account for approximately 30% of female patients with secondary coronary artery entrapment, which may occur from 5 weeks of gestation to 2 years postpartum, with an incidence rate of 1.81/100,000 pregnancies [3].
Etiology
Pathogenesis
The direct cause of primary coronary artery entrapment is damage to the artery wall tissue or endothelium caused by coronary artery intimal tear or coronary artery wall hemorrhage, the specific cause of the disease is still not completely clear, and there are a variety of factors that can increase the probability of the occurrence of this disease.
Secondary coronary artery entrapment is often caused by medical injury, such as cardiovascular surgery or interventional therapy damage to the coronary artery lining of the coronary artery formation of coronary artery entrapment, and in some cases, chest trauma, etc. may also lead to the occurrence of coronary artery entrapment.
Predisposing factors
Primary coronary artery entrapment
Coronary atherosclerosis
Atherosclerosis is the main cause of coronary artery entrapment. Coronary atheromatous plaques may cause rupture and bleeding of the trophoblastic vessels within the coronary artery wall, and when the amount of bleeding is large, it may cause a large entrapment between the intima-media and the intima-media of the arterial wall, which may lead to acute myocardial infarction in severe cases [4].
Atherosclerosis risk factors
Patients with hypertension, hyperlipidemia, diabetes mellitus and other diseases are prone to damage to the cardiovascular lining, with a higher risk of coronary atherosclerosis, and their risk of coronary artery entrapment is also increased.
Pregnancy
Elevated estrogen levels, increased total blood volume and cardiac output, and a sharp increase in vessel wall pressure due to exertion during labor and delivery during pregnancy cause structural changes in the arterial wall, which in turn are more likely to predispose to coronary artery entrapment [5].
Medication
Taking medications such as estrogen and birth control pills may alter estrogen levels in the body, thereby increasing the risk of spontaneous coronary artery entrapment [5].
Drug use
Drug use is also a trigger for the development of coronary artery entrapment. Drugs such as cocaine increase sympathetic nerve activity in blood vessels and cause an increase in blood pressure, which together result in increased shear forces on the vessel wall and dramatic changes in blood pressure, causing tearing of the arterial lining in the long term and leading to the development of arterial entrapment.
Secondary coronary artery entrapment
Invasive Surgery and Instrumentation Factors
The risk of coronary artery entrapment is increased by inappropriate catheter diameter, excessive catheter insertion, repeated dilatation of the balloon, and rupture of the balloon during interventional procedures.
Predisposing factors
Genetic Diseases
Some genetic diseases affect the structure of coronary artery wall, causing degenerative changes of coronary artery intima-media, cystic intima-media necrosis and focal elastic fiber breaks, which increase the risk of artery entrapment, such as fibromuscular dysplasia, Marfonte’s syndrome, LoeysDietz syndrome patients have a significantly increased risk of coronary artery entrapment.
Inflammatory factors
Some systemic inflammatory diseases may involve the coronary arteries, such as systemic lupus erythematosus, polyarteritis nodosa, tuberculosis, Kawasaki’s disease, giant cell arteritis, inflammatory bowel disease, etc. These diseases usually affect the structural strength of coronary artery walls through chronic vascular inflammation, which increases the risk of coronary artery dissection.
Mental and psychological factors
The impact on female patients is greater, and relevant studies have shown that when emotional stress or great emotional trauma causes emotional changes, the level of catecholamines secreted by the body rises, so that the endothelial cells of the coronary arteries are subjected to an increase in the shear force, and it is more likely that coronary artery entrapment occurs on the basis of coronary artery structural lesions [6].
Pathogenesis
The pathogenesis of spontaneous coronary artery entrapment is still unknown, and many of the risk factors mentioned above may increase the risk of the disease. Female patients with coronary artery entrapment usually have fewer combinations of traditional cardiovascular risk factors, which are hypothesized to be related to increased shear force on coronary endothelial cells, tortuous coronary arteries, and structural weaknesses of coronary artery vessel walls, and so on.
There are currently two main speculations about the pathogenesis: either endothelial and intima-media discontinuity or intima-media tear that allows blood from the true lumen to cross the intima-media elastic plate into the intima-media layer to aggregate and create a false lumen, or spontaneous rupture of the middle trophoblastic vessels with increasing density to form an internal hematoma in the coronary wall, which forms an entrapment and compresses the true lumen [7].
Secondary coronary pathogenesis is clearer and is mainly due to entrapment hematoma formation caused by intimal rupture due to medical injury.
Symptoms
Main symptoms
The main symptoms of arterial entrapment are related to the site of occurrence and severity and are described below.
Pain
Pain is the most common symptom of coronary artery entrapment. The nature of the pain can vary, and patients often describe it as burning, tearing, or cutting pain in the chest and heart, sometimes radiating to the upper extremities, back of the shoulders, and jaw.
Ventricular arrhythmia
Ventricular arrhythmia is an arrhythmia caused by myocardial ischemia due to coronary artery entrapment, which is often characterized by a rapid heartbeat or a fluttering sensation in the chest.
Other symptoms
Depending on the patient’s condition, other symptoms such as chest tightness and shortness of breath, excessive sweating, fatigue, nausea and vomiting, and dyspnea may occur.
Complications
Myocardial infarction
After the formation of coronary artery entrapment, the false lumen of the hematoma will compress the true lumen of the blood vessel, thus reducing the blood flow of the coronary artery, and the blood supply to the coronary artery will be reduced or even interrupted. Myocardial infarction is a common and serious complication of coronary artery entrapment, which occurs when there is persistent ischemia of the myocardium.
Heart failure
It usually occurs after coronary artery dissection is cured, and is usually caused by myocardial ischemia, resulting in myocardial damage and impaired cardiac function, and cardiac blood output is unable to meet the body’s tissue metabolic needs and complications.
Medical Treatment
Department of Medicine
Cardiovascular Medicine
It is recommended to consult the Department of Cardiovascular Medicine if you experience panic attacks, chest pain, or if an abnormal heart rhythm is detected during a physical examination.
Emergency Department
Patients with serious conditions such as shock, coma, severe chest pain, etc. should be immediately sent to the Emergency Department or Chest Pain Center for resuscitation.
Preparation for medical treatment
Consultation: registration, preparation of information, common problems
Tips for seeking medical treatment
Since coronary artery entrapment can be an acute and fatal condition, patients with suspected coronary artery entrapment should be sent to the emergency department or chest pain center for examination as soon as possible to avoid delayed treatment.
For patients with non-acute coronary artery dissection, it is important to organize the patient’s recent medical, medication, surgical, and family genetic history in advance, so that the physician can more accurately determine the patient’s condition with the relevant information.
Preparation List
Symptom list
Especially need to pay attention to the time of occurrence of symptoms, special performance, etc.
Where does the body feel uncomfortable? When did the discomfort start?
Is there any noticeable pain in the chest, back of the shoulder or surrounding areas? How long has the pain lasted? Describe exactly what the pain feels like?
Were there any obvious triggers before or after the onset of symptoms?
Were there any symptoms such as irritability, limb weakness, nausea and vomiting, profuse sweating, or difficulty breathing?
List of medical history
Is there a history of hypertension, hyperlipidemia or atherosclerosis?
Any history of cardiac or arterial malformations?
Any recent pregnancies?
Have there been any recent stressful situations or major changes in your life?
Any recent history of cardiac surgery or interventional procedures involving the arteries?
Any history of drug abuse?
Is there a history of equine syndrome or any other family genetic disorder?
Are there any cases of systemic lupus erythematosus, arteritis, or other systemic inflammatory diseases?
Is there a family history of coronary artery entrapment in the family and loved ones?
Have you been treated at another medical facility since the onset of symptoms?
Checklist
Test results from the last six months, which can be brought with you to the doctor’s office
Electrocardiogram (ECG) results
X-ray chest radiograph
Results of coronary color ultrasound
Computed Tomography Angiography (CTA) test results
Magnetic Resonance Angiography (MRA) test results
Medication List
Medications used in the last 3 months, if available in boxes or packages, bring them to the doctor’s office
Hypertensive medications: sodium nitroprusside, captopril, etc.
Diuretic medications: aldosterone, hydrochlorothiazide, etc.
Sex hormone drugs: estrogen, progesterone drugs and contraceptive drugs.
Other drugs: drugs taken in daily life to treat other diseases (including Chinese herbs, supplements, vitamins, etc.).
Diagnosis
Diagnosis is based on
Medical history
The possibility of coronary artery entrapment should be considered in patients with hypertension and atherosclerosis.
The possibility of coronary artery entrapment should be considered in patients with a history or family history of genetic disorders affecting arterial organization, such as Marfan syndrome and fibromuscular dysplasia.
The possibility of coronary artery entrapment due to medical injury should be considered in patients who have undergone cardiovascular surgery or intervention.
The possibility of coronary artery entrapment during pregnancy should be considered in female patients with a recent history of pregnancy.
The possibility of coronary artery dissection should be considered in patients who have recently experienced a stressful or traumatic event.
Clinical manifestations
The main symptom of coronary artery entrapment is severe pain, so consider the possibility of coronary artery entrapment when the chest and back pain described above occurs.
Tachycardia, restlessness, excessive sweating, nausea and vomiting should be considered as symptoms of insufficient blood supply to the myocardium due to coronary artery entrapment.
Since some coronary artery entrapment diseases have an acute onset and rapid progression, once coronary artery entrapment is suspected, imaging examinations should be performed as soon as possible to confirm the morphology and severity of the entrapment, which will facilitate the subsequent treatment.
Electrocardiography and imaging
Chest X-ray and electrocardiogram (ECG): have no specific value in the diagnosis of coronary artery entrapment, but ECG can differentiate acute myocardial infarction.
Color ultrasound of arterial vessels: it can check the location of the true and false lumen of coronary artery entrapment as well as the status of blood flow, and can assist in the detection of possible organic lesions of the coronary arteries.
Computed tomography angiography (CTA): with the advantages of non-invasive and high spatial resolution, it has high value for the diagnosis of coronary artery entrapment.
Magnetic resonance angiography (MRA): has high value in the evaluation of coronary artery entrapment, can find the earlier coronary artery entrapment lesions, compared with the CTA to show the vascular structure is more clear, can improve the sensitivity and specificity of the diagnosis of arterial entrapment [8].
Intraluminal imaging techniques: intravascular ultrasound (IVUS), optical coherence tomography (OCT), etc. are helpful in the identification and diagnosis of coronary artery entrapment.
Differential diagnosis
Acute myocardial infarction
The typical symptom of both coronary artery entrapment and acute myocardial infarction is severe pain in the anterior chest and back. However, coronary artery entrapment can be used as a differential diagnosis without electrocardiographic changes (ST-T segment changes) and elevated markers of myocardial injury (e.g. troponin). It should be noted that coronary artery entrapment may cause complications of acute myocardial infarction as the disease progresses.
Stress cardiomyopathy
Also known as Takotsubo (octopus can) cardiomyopathy, this disease is also common in women, and is characterized by chest pain and other symptoms of myocardial infarction, which can be differentiated by coronary angiography.
Treatment
Aims of treatment: to restore blood flow to the heart, to relieve chest pain, and to prevent complications and recurrence of entrapment.
Principle of treatment: There is no standardized treatment, and physicians usually choose drug treatment or surgical intervention according to the severity of arterial entrapment.
Emergency treatment
For patients with acute onset of coronary artery entrapment or myocardial infarction caused by entrapment, it mainly includes maintaining the basic vital signs of the patient, monitoring hemodynamic indexes (blood pressure, heart rate, etc.) and electrocardiographic monitoring, ensuring that the patient is absolutely bedridden and resting, and supporting the patient with strong sedatives and analgesics.
Medication
There are two modes of drug treatment for coronary artery entrapment: one is conservative drug treatment when the severity of the entrapment is mild and the blood flow in the distal coronary artery is stable and there is no obvious persistent ischemia; the other is supportive drug treatment and symptomatic drug treatment during surgical treatment.
Pharmacologic conservative treatment
This usually includes antihypertensive drugs (spironolactone, chlorosartan, verapamil, etc.). Anticoagulants and antiplatelet agents are generally not used during pregnancy to avoid the risk of hematoma enlargement within the coronary artery wall.
Antiplatelet therapy/anticoagulation
The aim is to avoid thrombotic events during interventions.
Antiplatelet therapy can be performed with aspirin and clopidogrel, and anticoagulation can be performed with drugs such as normal heparin, low molecular heparin or warfarin.
Both treatments are still controversial, and their application to coronary artery entrapment may carry the risk of prolonging bleeding time and enlarging hematomas within the arterial wall, and should be restricted to acute administration only during hemodialysis.
Symptomatic drug therapy
Pharmacologic therapy mainly for chest pain symptoms, commonly used drugs are nitrates and calcium channel blocker drugs, such as nitroglycerin, nifedipine, isobarbital, thiazoxazone, and so on.
Surgery
Percutaneous coronary intervention (PCI)
On the basis of coronary angiography, the therapeutic device is sent into the distal end of coronary artery entrapment through various ways to close the entrapment, dredge the narrowed or even occluded coronary artery lumen, so as to improve the myocardial blood perfusion of the therapeutic method.
Including percutaneous coronary endoluminal angioplasty and coronary stenting. Currently, the success rate of coronary intervention is not high, and the probability of complications is high, so it is necessary to strictly consider whether the indications for surgery before treatment.
Coronary Artery Bypass Graft (CABG)
Coronary artery bypass grafting (CABG) is also known as coronary artery bypass grafting, which is usually applied to the failure of percutaneous coronary intervention with persistent ischemic coronary artery entrapment. It is a surgical method that uses vascular grafting to establish a blood supply channel between the body circulation and the diseased area of the stenotic segment of the coronary artery, and supplies blood to the myocardium in the diseased coronary artery supply area via the bridging vessel.
Its early therapeutic results are favorable, but there is still the possibility of graft attenuation, competition for blood flow from healing of the original coronary artery, and thrombosis [9].
Prognosis
Cure.
Patients with coronary artery entrapment have a better overall prognosis, with a lower long-term morbidity and mortality rate in surviving patients.
The overall prognosis is better as soon as possible, but non-acute coronary artery entrapment usually requires medical attention as soon as possible as well, or it may also develop into a serious event such as myocardial infarction, which can be life-threatening.
Prognostic factors
Prognostic outcomes are related to when the patient receives treatment, and the earlier the patient receives treatment, the more likely he or she is to avoid a poorer prognosis. Timely detection of entrapment during intervention is critical.
When interventional procedures are used to treat coronary artery entrapment, there are many prognostic factors, including stroke, recurrence of the entrapment, and spread of the hematoma, among other post-procedural complications.
Hazards
Patients with coronary artery entrapment have a relatively high rate of recurrence, and may also feel post-treatment discomfort due to complications if an interventional approach is used.
Intermediate and long-term adverse cardiovascular events are more common in the prognosis of patients with coronary artery entrapment, such as myocardial infarction, chronic heart failure, ischemic stroke, etc. Extra attention should be paid to good regular medical checkups and prevention of disease recurrence.
Daily
Daily management
After treatment, patients should take medication regularly as prescribed by the doctor, and should try to avoid strenuous exercise, chest collision, emotional excitement and other behaviors that may lead to recurrence of entrapment.
Maintain a low-salt, low-fat diet, and try to avoid the intake of strong tea, coffee, alcohol and other factors that may stimulate the recurrence of entrapment.
Follow-up and review
Patients should maintain regular checkups and cardiovascular status examinations, and actively receive post-discharge follow-up. Regular physical examination and review can help detect recurrence of entrapment or adverse cardiovascular events in time and take timely treatment measures.
Prevention
The main focus is on controlling blood pressure, minimizing the impact of blood flow pressure on the vessel wall, and avoiding actions that can cause strong changes in heart rate and blood pressure in daily life, such as straining to go to the toilet, taking cold showers, avoiding prolonged exposure to noisy environments, and avoiding events or factors that can cause agitation as much as possible [10].
Atherosclerotic risk factors such as hypertension, hyperlipidemia and diabetes mellitus are also important risk factors for the occurrence of coronary artery entrapment, and extra vigilance should be exercised for the occurrence of arterial entrapment when suffering from the above diseases.
Interventional procedures should be standardized to avoid violent use of instruments. Accumulate experience to recognize the entrapment as early as possible and take timely remedial measures.