Optical Coherence Tomography in the Management of
               Intermediate Lesion in a Patient with Acute Coronary Syndrome

Optical coherence tomography provides high-resolution tomography imaging of the coronary microstructure, allowing for detailed characterization of atherosclerotic plaque components and morphology, in addition to an accurate determination of vascular dimensions. We report the case of a patient with an intermediate coronary lesion, presenting in the subacute phase of a myocardial infarction, in whom optical coherence tomography was used as an adjunctive diagnostic method to aid in the decision-making process and to guide the interventional procedure.

Arteriosclerosis; Myocardial infarction; Coronary stenosis; Tomography, optical coherence; Percutaneous coronary intervention; Stents

Authorship

Evandro Martins Filho

Daniel Chamié Correspondence to: Daniel Chamié. Avenida Dr. Dante Pazzanese, 500 - Vila Mariana - CEP: 04012-180 - São Paulo, SP, Brazil. Email: daniel.chamie@gmail.com

Áurea J. Chaves

Alexandre Abizaid

SCIMAGO INSTITUTIONS RANKINGS

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de CardiologiaBrazilSão Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil

Figures

Figures (4)

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Figure 1
Coronary angiography. The left coronary artery showed slight parietal irregularities without significant obstruction (A, B, and C). The right coronary artery showed moderate segmental injury in its middle third, with preservation of distal flow (D). The contractile function of the left ventricle was preserved. Left ventriculography in diastole (E); left ventriculography in systole (F).

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Figure 2
Quantitative coronary angiography (A and B). Quantitative coronary angiography of the lesion in the middle third of the right coronary artery, confirming the presence of a moderate stenosis. The minimal luminal diameter was 1.40 mm and the diameter stenosis rate was 51.4%.

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Figure 3
Pre-procedure. Angiography of the right coronary artery (A). Longitudinal section of three-dimensional reconstruction of images obtained with optical coherence tomography. The green lines identify the proximal and distal references to the stenosis, and the red line, the minimum luminal area (B). Tomographic images of the cross section of the vessel. The minimum lumen area measured 1.83 mm2, with a stenosis area of 76%. The segment length was 28.4 mm (C). Tomographic images of the cross section of the vessel at the minimum lumen area (D1 and D2). Note the presence of a large lipid plate (area with low intensity of the light signal, with poorly defined edges), rupture of the fibrous cap (D2), and a large residual thrombus load, predominantly composed of erythrocytes (red thrombus; irregular mass adhered to the vessel wall, which causes severe attenuation of the light signal, with posterior shadowing). It is also noted that in the rupture site (D2), the thickness of the remaining fibrous layer measured 60 μm. Fly-through view of the three-dimensional reconstruction, showing great thrombotic load, with an eccentric distribution, adhered to the vessel wall at the site of minimum lumen area (E).

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Figure 4
Postprocedure. The top panel shows the right coronary angiography after implantation of a zotarolimus-eluting stent measuring 3.0 × 30 mm, with post-dilatation with a noncompliant balloon measuring 3.5 × 15 mm. The central panel shows a longitudinal image obtained from optical coherence tomography, while the bottom panel displays images of the cross section of the vessel. The green lines identify the proximal and distal references of the target vessel. The red line indicates the smaller area of the stent after the procedure, while the white lines show random regions of the stent in the distal, middle and proximal segments. Note the uniform expansion of the stent, the absence of poor apposition of its stems and of dissection of its edges. The smallest area of the stent measured 5.57 mm², located near its distal edge – only 1.4% larger than the average luminal areas from references, indicating an adequate expansion of the prosthesis.

Figure 1 Coronary angiography. The left coronary artery showed slight parietal irregularities without significant obstruction (A, B, and C). The right coronary artery showed moderate segmental injury in its middle third, with preservation of distal flow (D). The contractile function of the left ventricle was preserved. Left ventriculography in diastole (E); left ventriculography in systole (F).

Figure 2 Quantitative coronary angiography (A and B). Quantitative coronary angiography of the lesion in the middle third of the right coronary artery, confirming the presence of a moderate stenosis. The minimal luminal diameter was 1.40 mm and the diameter stenosis rate was 51.4%.

Figure 3 Pre-procedure. Angiography of the right coronary artery (A). Longitudinal section of three-dimensional reconstruction of images obtained with optical coherence tomography. The green lines identify the proximal and distal references to the stenosis, and the red line, the minimum luminal area (B). Tomographic images of the cross section of the vessel. The minimum lumen area measured 1.83 mm2, with a stenosis area of 76%. The segment length was 28.4 mm (C). Tomographic images of the cross section of the vessel at the minimum lumen area (D1 and D2). Note the presence of a large lipid plate (area with low intensity of the light signal, with poorly defined edges), rupture of the fibrous cap (D2), and a large residual thrombus load, predominantly composed of erythrocytes (red thrombus; irregular mass adhered to the vessel wall, which causes severe attenuation of the light signal, with posterior shadowing). It is also noted that in the rupture site (D2), the thickness of the remaining fibrous layer measured 60 μm. Fly-through view of the three-dimensional reconstruction, showing great thrombotic load, with an eccentric distribution, adhered to the vessel wall at the site of minimum lumen area (E).

Figure 4 Postprocedure. The top panel shows the right coronary angiography after implantation of a zotarolimus-eluting stent measuring 3.0 × 30 mm, with post-dilatation with a noncompliant balloon measuring 3.5 × 15 mm. The central panel shows a longitudinal image obtained from optical coherence tomography, while the bottom panel displays images of the cross section of the vessel. The green lines identify the proximal and distal references of the target vessel. The red line indicates the smaller area of the stent after the procedure, while the white lines show random regions of the stent in the distal, middle and proximal segments. Note the uniform expansion of the stent, the absence of poor apposition of its stems and of dissection of its edges. The smallest area of the stent measured 5.57 mm², located near its distal edge – only 1.4% larger than the average luminal areas from references, indicating an adequate expansion of the prosthesis.

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Optical Coherence Tomography in the Management of Intermediate Lesion in a Patient with Acute Coronary Syndrome

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