A honeycomb-like structure in the left anterior descending coronary artery treated using a scoring device and drug-eluting stent implantation: a case report

Diagnosis and treatment of angiographically unclear coronary lesions

Although selective coronary angiography is the gold standard diagnostic technique for coronary lesions, this method does not provide all information regarding pathophysiologic mechanisms. We herein describe a patient in their early 60s with a 3-month history of pronounced angina. Coronary angiography revealed a central line of illumination in the proximomedial segment of the right coronary artery, suggesting a chronic coronary dissection/recanalized thrombus, along with positive remodeling and TIMI grade 2 flow. Optical coherence tomography showed a recanalized thrombus and multiple lumens separated by thin septa. Because of the significantly reduced flow and signs of ischemia in the right coronary artery irrigation territory, we decided to perform percutaneous coronary intervention. Post-treatment optical coherence tomography indicated optimal apposition and expansion of the stents with positive remodeling of the blood vessel. We believe that decisions regarding treatment modalities should be guided by the presence or absence of ischemia. Lesions that are causing myocardial ischemia should be revascularized; otherwise, medical treatment can be utilized.

Honeycomb-like structure (HLS) in the left anterior-descending coronary artery-recanalized thrombus demonstrated by intravascular ultrasound (IVUS) in a patient with polycythemia vera and thrombocythemia

A 71 year old male patient who experienced acute myocardial infarction (AMI) 4 years ago and had a history of polycythemia vera and thrombocythemia was admitted because acute attack of chronic heart failure. Coronary angiography revealed an unusual filling defect in the middle segment of the left anterior descending (LAD) coronary artery and IVUS showed it is a HLS which is different from dissection or woven coronary artery. We review the recent literature of HLS in this article and further investigations are warranted for the optimal management of HLS.

Optical coherence tomography-assisted interventional treatment of a woven coronary artery: a case report

BACKGROUND

A woven coronary artery is a rare feature on coronary angiography. Distinguishing woven-like change and recanalization of an occluded artery is difficult.

CASE PRESENTATION

A 59-year-old man was admitted to the hospital for chest tightness. Coronary angiography showed a woven coronary artery at the middle segment of the left anterior descending branch (LAD). The middle segment of the right coronary artery (RCA) exhibited 99% occlusion. A 3.5 × 26-mm drug-eluting stent was implanted in the middle segment of the RCA. One week later, we examined the LAD using optical coherence tomography (OCT). Considering the patient's medical history and the results of OCT, a 2.7 × 38-mm drug-eluting stent was inserted into the LAD. Re-examination by OCT indicated that the stent was well attached to the wall, with no dissection at the edge of the stent. Antiplatelet therapy and statin-based plaque stabilization were continued. No obvious abnormality was found during follow-up one year later.

CONCLUSIONS

OCT can help distinguish woven-like change and recanalization of an occluded coronary artery. The evaluation and formulation of treatment strategies for a woven coronary artery are important.

Anatomical features and clinical outcome of a honeycomb-like structure in the coronary artery: reports from 16 consecutive patients

BACKGROUND

Recanalization of thrombus in coronary artery tree is defined as a honeycomb-like structure. However, the anatomic features and appropriate treatment of honeycomb-like structure still remain largely unclear.

METHODS AND RESULTS

Between 2014 July and 2017 December, 17 honeycomb-like structure in 16 patients based on optical coherence tomography and intravascular ultrasound were included. Fractional flow reserve was measured for patients who had thrombolysis in myocardial infarction flow grade 3. Angiographic and optical coherence tomography/intravascular ultrasound-derived variables were studied. Clinical events (until to 2018 December) were collected. Honeycomb-like structures mostly involved left anterior descending artery (68.8%) and localized at proximal-mid (88.2%) segment of vessels. Eight patients had a side branch ≥ 2 mm in diameter taking from honeycomb-like structure. Only one patient had a normal fractional flow reserve. Fifteen patients underwent implantation of a stent. Stent implantation was associated with side branch compromise or closure (4 in each). Of 4 patients with side branch closure, all had a creatine kinase myocardial band > 5 times increase in hospital, with 3 deaths and 1 target lesion revascularization during follow-up.

CONCLUSIONS

Despite the presence of recanalization, most honeycomb-like structure lesion have a positive fractional flow reserve. Further study is required to address how to protect a large side branch taking from honeycomb-like structure.

Differential Diagnosis, Clinical Characteristics, and Interventions of Braid-Like Coronary Artery: Case Series Analysis Based on Optical Coherence Tomography

Aim

Based on optical coherence tomography (OCT), we aimed to determine the diagnosis, clinical characteristics, and interventions of braid-like coronary arteries, which are rare and tend to be diagnosed as a woven coronary artery (WCA) anomaly.

Methods and Results

We identified braid-like lesions on coronary angiography (CAG) in 7 patients (6 men; median age 47 years; age range 26 to 57 years). All patients were heavy smokers. Four patients were diagnosed with an old myocardial infarction and the other 3 with unstable angina. The braid-like lesions were located in the left anterior descending arteries in 2 patients and in the right coronary arteries in the other 5. TIMI grade 2 flow was observed in all involved vessels. OCT findings of all lesions were consistent with recanalization of organized thrombi, which consisted of septa that divided the lumen into multiple small cavities communicating with each other. No separate three-layered structure could be defined. Based on the significance of the stenosis and its related symptoms, drug-eluting stents were implanted in all of the lesions. All patients experienced symptomatic improvement after the intervention and were followed up event-free for 12 months.

Conclusions

Braid-like coronary arteries are likely to undergo recanalization of organized thrombi rather than WCA according to our OCT findings. The majority of cases affect men who smoke heavily. Percutaneous stent implantation may be beneficial in selected patients when feasible.

Optical Coherence Tomography for In Vivo Identification, Characterization and Optimal Treatment of Spontaneous Recanalization of Coronary Thrombus

BACKGROUND/AIM

Spontaneous recanalization of coronary thrombus (SRCT) is a rare in vivo appearance, with a nonspecific angiographic aspect. The aim of this study was to investigate the importance of optical coherence tomography (OCT) use for SRCT identification, characterization of pathogenic mechanisms and optimal treatment.

PATIENTS AND METHODS

We retrospectively analyzed all patients with angiographic suspicion of SRCT who underwent coronary angiography for suspected coronary artery disease and afterward investigated by OCT imaging.

RESULTS

We identified 28 cases with angiographic suspicion of SCRT (0.41% of CA) and confirmed it in 4 patients (0.05% of CA). OCT provided insight about the underlying SRCT mechanism: possible complicated atherosclerotic plaques in two cases and, respectively, spontaneous coronary artery dissection in other two cases. OCT provided accurate lesion assessment and offered optimal PCI materials selection.

CONCLUSION

Besides providing the diagnosis, OCT also improved characterization of SRCT pathogenic mechanisms, in the four confirmed SRCT cases, supporting the role of coronary wall in situ complications, namely dissection of an atherosclerotic plaque or spontaneous dissection of a normal coronary wall.

Rotational Atherectomy for Ablation of Multiple Channel Structure Observed by Optical Frequency Domain Imaging

Patient: Male, 71

Final Diagnosis: Silent myocardial infarction

Symptoms: Dynpnea

Medication: —

Clinical Procedure: —

Specialty: Cardiology

A patient with multiple Swiss cheese aspect coronary lesions: optical coherence tomography to guide coronary angioplasty

Although spontaneous recanalization of coronary thrombi has been reported pathologically, it is rarely recognized in clinical practice. We presented a rare case of recanalized thrombi of the right coronary artery and distal left anterior descending artery in a patient with an anterior ST segment elevation myocardial infarction treated with primary percutaneous intervention of the proximal left anterior descending artery. Optical coherence tomography aspect of right coronary artery was consistent with a 'Swiss cheese' appearance that represented recanalization of organized thrombi. Optical coherence tomography has been essential to discriminate the underlying mechanism and may provide useful information for an appropriate treatment approach.

Honeycomb-like structure in the right coronary artery treated with a drug-eluting stent: a case report and literature review

A honeycomb-like structure (HLS) is a rare entity encountered in catheterization laboratories. The etiology of HLS remains elusive. Moreover, no treatment guideline or consensus for HLS has been proposed. However, with more frequent adoption of intravascular imaging modalities, the number of cases of HLS is rising. We herein present a case of HLS and summarize previous reports in the literature with the aim of providing useful information for interventional cardiologists and promoting further research.

Diagnosis and Management of Spontaneously Recanalized Coronary Thrombus Guided by Optical Coherence Tomography - Lessons From the French "Lotus Root" Registry

BACKGROUND

Spontaneous reanalyzed coronary thrombus (SRCT) has been reported in autopsy series, but little is known about SRCT, and it is potentially under-diagnosed in clinical practice.Methods and Results:SRCT identified on OCT were included in a French multicenter series, the Lotus Root French Registry. A total of 34 SRCT were identified on OCT in 33 patients (23 male; median age, 56 years; IQR, 52-65 years); 23/33 patients (70%) presented with angina pectoris and/or dyspnea. Three angiographic aspects were distinguished retrospectively: braided, pseudo-dissected, and hazy. Stenosis severity on quantitative coronary analysis varied between 11% and 100% (median, 45%), whereas the reduction in lumen area on OCT varied between 20% and 92% (median, 68%). A typical "lotus root" aspect was confirmed on OCT, consisting of multiple circular concave-edged channels of varying size, numbering between 3 and 12 depending on the slice, separated by smooth-edged septa of high luminosity without posterior attenuation. OCT also served to guide treatment, with stenting in 91% of cases. During the 17-month follow-up 91% of patients had excellent evolution. One death and 3 ACS events occurred.

CONCLUSIONS

In this large SRCT cohort, angiography had limited diagnostic value whereas OCT could be used to define disease characteristics and guide treatment of lesions inducing angina pectoris and/or silent myocardial ischemia. OCT-guided management was associated with good prognosis.