Combined use of drug-eluting stent and drug-coated balloon for tandem lesion with spontaneously recanalized coronary thrombus: insights from optical coherence tomography

Abstract

Figures

(A) Coronary angiography indicating tandem lesion (arrows) with a braid-like appearance in both the proximal and distal of RCA. (B) OCT imaging from cross section at (A) showing a lotus root-like appearance. (C) OCT imaging from cross section at (B) showing a lotus root-like appearance and mural thrombi (asterisk). (D) Cross-sectional OCT image of the proximal RCA after lesion preparation, demonstrating a major dissection extending into media (arrowhead). (E) Cross-sectional OCT image at (A) after preparation, showing well-controlled dilatation and an adequately enlarged lumen. (F) Cross-sectional OCT image at (B) after preparation, demonstrating a major dissection extending into the media (arrowhead) and residual plaque volume. (G) Final angiography of PCI showing lesions treated with DES and DCB. (H) Coronary angiography at the one-year follow-up. (I) OCT imaging from the cross-section at (C), which had been treated with DCB. DCB, drug-coated balloon; DES, drug-eluting stent; MLA, minimum lumen area; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; RCA, right coronary artery.

Full text

Case description

A 70-year-old woman with type 2 diabetes mellitus presented with progressive chest pain on exertion following an episode of sudden chest pain at rest two weeks earlier. Coronary angiography revealed a severe stenosis with a braid-like appearance extending from proximal to distal segments of the right coronary artery (RCA) (Figure 1A, arrows). Angiography suggested a spontaneously recanalized coronary thrombus (SRCT), which previous reports indicate is often physiologically significant.^1^

(A) Coronary angiography indicating tandem lesion (arrows) with a braid-like appearance in both the proximal and distal of RCA. (B) OCT imaging from cross section at (A) showing a lotus root-like appearance. (C) OCT imaging from cross section at (B) showing a lotus root-like appearance and mural thrombi (asterisk). (D) Cross-sectional OCT image of the proximal RCA after lesion preparation, demonstrating a major dissection extending into media (arrowhead). (E) Cross-sectional OCT image at (A) after preparation, showing well-controlled dilatation and an adequately enlarged lumen. (F) Cross-sectional OCT image at (B) after preparation, demonstrating a major dissection extending into the media (arrowhead) and residual plaque volume. (G) Final angiography of PCI showing lesions treated with DES and DCB. (H) Coronary angiography at the one-year follow-up. (I) OCT imaging from the cross-section at (C), which had been treated with DCB. DCB, drug-coated balloon; DES, drug-eluting stent; MLA, minimum lumen area; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; RCA, right coronary artery.

Optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI), which is associated with favourable outcomes,^2^ was performed. OCT imaging revealed a tandem lesion with lotus root-like appearances and mural thrombi (Figure 1C, asterisk) extending over 100 mm (Figure 1B and C). Although optimal PCI strategy for SRCT is not well established, drug-eluting stents (DES) implantation has shown promising results, and drug-coated balloons (DCB) may offer an alternative.^3^ Following adequate lesion preparation with a cutting balloon, angiography showed residual stenosis greater than 50% in proximal and distal segments while mid segment had comparatively less stenosis. Additionally, OCT revealed that the proximal and distal lesions had developed major dissections extending to the media (Figure 1D and F, arrowheads), whereas the mid lesion demonstrated a well-controlled dissection with relatively less plaque volume (Figure 1E). To minimize risks associated with full coverage of RCA using multiple overlapping DES, a hybrid approach using DES and DCB was adopted (Figure 1G).

One year after treatment, she developed exertional dyspnoea with progression in the left anterior descending artery. OCT-guided PCI was performed for the de novo lesion, and RCA was examined. Angiography of RCA demonstrated sustained patency of the treated lesion (Figure 1H). OCT imaging at the DCB-treated site showed favourable expansion at minimum lumen area (Figure 1I). This case highlights the successful use of combined DES and DCB therapy for extensive SRCT, suggesting its potential as a viable treatment strategy.

Supplementary Material

ytag194_Supplementary_Data