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

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.

Optical coherence tomography characterization of spontaneous recanalized coronary thrombus - Single center experience

Introduction: Recanalized thrombus is an under diagnosed clinical entity. Aim was to investigate the utility of optical coherence tomography (OCT) in identifying spontaneously recanalized thrombi (SRCT) for management in clinical practice. Methods: This was a retrospective study analyzing 2678 coronary angiograms over a 4-year period which included intravascular imaging guidance in 75.8% of the percutaneous coronary interventions (PCI). Angiographic suspicion of SRCT has hazy appearance seen in 34 patients. Results: Eight patients (7 males and 1 female) were confirmed with SRCT on OCT and two underwent intravascular ultrasound (IVUS). Median age was 52 years (range 33-67 years). Based on clinical symptoms, diagnosis was STEMI-2, NSTEMI-1, unstable angina-3 and chronic stable angina-2. Angiographic patterns were veiled/hazy appearances in 3; braided in 2; pseudo dissection in 2; and near occlusion in 1 patient. OCT findings displayed multiple small cavities, signal-rich with high backscattering and thin septa with smooth inner borders dividing the lumen and intercommunications. Presence of multiple holes conferred typical "Swiss cheese" or 'lotus root' like appearance, characteristic of recanalized thrombi. SRCT lesion length was (median interquartile ranges [IQR], 16.5[12.07-21.5] mm) and minimal luminal area (median [IQR], 1.77 [0.93-3.26] mm²) with significant stenosis (median [IQR], 74.0[67.0-81.0] %). Minimum/maximum number of channels were (median [IQR], 2.0[2.0-2.0]) and (median [IQR], 4.50[4.0-6.75]) respectively. Lipid rich plaque was predominant. IVUS demonstrated echo-lucent channels with small cavities. All but one patient underwent PCI. Conclusion: Intravascular imaging by OCT delineates the characteristics of recanalized thrombi and distinguishes ambiguous lesions. Majority of the lesions involving SRCT were significant both symptomatic and stenosis severity wise on OCT requiring PCI.

Refractory hypertension secondary to renal artery stenosis with a honeycomb-like structure

Background

A honeycomb-like structure (HLS) is a rare abnormality characterized by a braid-like appearance. Angiograph and intravascular examination, including coherence tomography and intravascular ultrasound (IVUS), can further confirm the multiple intraluminal channels or honeycomb structure, which can also be described as looking like ‘swiss cheese’, a ‘spider web’ or a ‘lotus root’. Previous studies have mostly reported this abnormality in coronary arteries, with a few cases in renal arteries. More information about the characteristics and development of HLS is needed.

Case presentation

A 69-year-old Han man with resistant hypertension received abdominal enhanced computerised tomography and was revealed to have left renal artery stenosis with the possibility of left renal infarction. Renal artery angiography confirmed a 95% stenosis located in the proximal segment of the left renal artery, and the middle segment was blurred with multi-channel-like blood flow. Further IVUS was performed and identified multiple channels surrounded by fibrous tissue. It was a rare case of HLS in the renal artery secondary to the thrombus, with organisation and recanalisation. Balloon dilatation and stent implantation at the proximal segment of the left renal artery were performed successfully. Blood pressure was well controlled after the procedure.

Conclusions

The IVUS findings are helpful for forming interventional therapeutic strategies for HLS lesions in the renal artery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02428-1.

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.

Spontaneously Recanalised Coronary Thrombus in the Left Anterior Descending Artery Presenting as Ventricular Tachycardia

Spontaneously recanalized coronary thrombus (SRCT), also known as honeycomb, lotus root or Swiss-cheese lesion, is an increasingly recognised finding in patients undergoing coronary angiography. It is thought to arise from partial resorption of an initially occlusive thrombus. Most patients present with angina or exertional breathlessness. We describe a case of a 69-year-old patient who presented with ventricular tachycardia and was found to have SRCT in the left anterior descending artery on coronary angiography. Echocardiography and left ventricular (LV) angiography showed an akinetic, aneurysmal, thin-walled LV apex, diagnostic of an old anterior infarct. We highlight the role of optical coherence tomography in making the diagnosis and discuss the available management options of this condition.

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.