A 72-year-old man with critical limb ischemia of the right lower extremity was referred for revascularization. His peripheral angiography showed severely calcified total occlusions of the right posterior tibial artery, peroneal arteries, and dorsalis pedis, with severe stenosis of the anterior tibial artery with collaterals (Figures 1A-1D). In order to assess the vascular effects of rotational orbital atherectomy, we performed intravascular imaging with virtual histology intravascular optical coherence tomography (VH-IVOCT) (Figures 2A-2F). We performed rotational orbital atherectomy of the calcified lesions in the anterior tibial artery using a 1.25 mm solid crown. Repeat angiography (Figure 1F) and VH-IVOCT (Figures ...

e present the case of a 63-year-old woman, former smoker, transferred to the catheterization laboratory for primary percutaneous coronary intervention in the midst of anterior ST-segment elevation myocardial infarction. Coronary angiography showed acute total occlusion of the proximal left anterior descending (LAD) (Video 1). After the guidewire passed through the distal LAD, TIMI-3 flow revealed severe proximal stenosis, which was treated with an everolimus-eluting stent with good outcome (Video 2). Afterward, angiographic haziness was recognized at the mid right coronary artery (RCA) (Figure 1A). Optical coherence tomography (OCT) exhibited non-occlusive thrombus (Figure 1B) and calcified plaques were observed proximal to ...

A 72-year-old male had acute inferior-wall myocardial infarction, for which he was subjected to primary angioplasty at another institute. Coronary angiography revealed a thrombotic 95% occlusion of the proximal right coronary artery (RCA) (Figure 1A). Percutaneous coronary intervention (PCI) was attempted but failed, as the coronary guidewire could not cross the lesion. There was TIMI 0 flow across the RCA at the end of the abandoned procedure (Figure 1B; Video 1). He was referred to our institute for a repeat PCI. Repeat coronary angiography revealed 95% eccentric calcified stenosis of the mid RCA with TIMI 3 flow (Figure 1C). The ...

A 66-year-old man presented with ST-segment myocardial infarction. He underwent successful Absorb 1.0 bioresorbable vascular scaffold (Abbott Vascular) implantation. A prespecified 12-month and 24-month coronary angiography and optical coherence tomography showed preserved vessel patency with signs of peristrut low-intensity areas within the neointima and features of atherosclerosis progression at the distal edge of the scaffold (Figure 1). A prespecified angiography at 60 months revealed a total occlusion at the distal part of the scaffold. Within the proximal edge, optical coherence tomography showed a complete absorption of stent struts with a decreased mean scaffold area and diameter (Figure 1). First-generation ...

A 75-year-old man underwent right transradial coronary angiography because of acute myocardial infarction. Postprocedural radial angiography revealed a dissection with a spiral luminal filling defect in the proximal radial artery corresponding to a National Heart, Lung, and Blood Institute type D dissection (Figure 1A; Video 1). In order to acquire a full, 360° optical coherence tomography (OCT) image, we withdrew the guidewire out of the sheath ahead of pullback and left the OCT imaging wire in the vessel alone. However, subsequent pullbacks were performed without any difficulties. Without the guidewire shadow, it was clear that the dissection started from a ...

A 52-year-old female was referred to our catheterization lab due to chest pain and stress-induced myocardial inferior ischemia. Coronary angiography revealed an abnormal segment of the right coronary artery (RCA); its lumen was divided into thin channels with a twisting course reassembling into a single normal lumen in the distal segment of the RCA with TIMI 3 blood flow (Figure 1A; Video 1 ). Optical coherence tomography (OCT) was performed to confirm the presence of a woven coronary artery anomaly (WCAA) (Figure 1B). The similarity of the angiogram to the braided hair gives the name to this entity. WCAA was first ...

A 20-year-old man presented with a severe headache and sudden-onset blurring of vision of 2-month duration. Fundus examination revealed hypertensive retinopathy in both eyes. His blood pressure was 190/120 mm Hg, for which amlodipine, telmisartan, and diuretics were started. Systemic examination was unremarkable. Routine serum biochemistry was normal; serum creatinine was 0.88 mg/dL and estimated glomerular filtration rate was 87 mL/min/1.73 m 2 . Ultrasound revealed small right kidney (5.8 x 3.4 cm) and normal-sized left kidney (9.4 x 4.3 cm). Computed tomography scan of the abdomen confirmed small right kidney ...

A 38-year-old male underwent successful recanalization of a chronic total occlusion (CTO) in a bare-metal stented segment of the mid right coronary artery (RCA) via retrograde approach. However, the in-stent restenotic lesion was undilatable despite pressure up to 35 atm with non-compliant (NC) OPN balloons (SIS Medical AG). The patient was discharged with plans for a future attempt. Six months later, coronary angiography revealed patency of the RCA with residual severe in-stent restenosis. Predilation with a 2.5 x 15 mm OPN NC balloon up to 35 atm confirmed the undilatable restenotic lesion with dog-boning effect. Therefore, coronary lithoplasty with ...

Longitudinal stent deformation (LSD), defined as the distortion or shortening of a stent in the longitudinal axis following successful stent deployment, has been recognized as an important complication of coronary angioplasty. It is caused by impact on a deployed stent by a device (such as a guide catheter or guide-catheter extension) or secondary devices (such as postdilation balloons) as a result of guidewire bias as well as the inherent mechanical properties of the stent itself. This complication may be difficult to detect angiographically, and the use of intravascular ultrasound or optical coherence tomography (OCT) can help confirm the diagnosis and ...

A 61-year-old male presented with anterior ST-segment elevation. Emergency coronary angiography demonstrated complete occlusion of the left anterior descending (LAD) coronary artery, which was treated with primary percutaneous intervention. Following predilation, a 2.5 mm x 38 mm Xience V drug-eluting stent (Abbott Vascular) was implanted. Due to coronary calcification, the distal portion of the stent was repeatedly postdilated with a 3 mm x 15 mm non-compliant balloon (NC Trek; Abbott Vascular) to ensure adequate stent expansion. The final angiographic result was good. The patient was readmitted 2 days later with recurrence of chest pain and anterior ST-segment elevation. Repeat ...

A 53-year-old man suffered a high-impact car collision. An increase in troponin levels was detected after 8 hours, so the patient underwent coronary angiography, which demonstrated an annular lesion in the proximal left anterior descending (LAD) artery (Figure 1A). Optical coherence tomography (OCT) showed an intimomedial flap and a double-lumen from the proximal to the mid LAD without significant atherosclerosis (Figure 1B). A 3.5 x 15 mm Magmaris direct magnesium resorbable scaffold (Biotronik) was deployed under OCT guidance. Then, progression of the hematoma to the mid LAD was observed, which precluded balloon postdilation and forced the implantation of a ...

A 43-year-old man presented to his cardiologist’s office with a history of exertion-related chest pain. His past medical history included type 2 diabetes mellitus, hypercholesterolemia, smoking, and a family history of coronary artery disease. His physical examination was normal. After positive exercise-induced chest discomfort, the patient underwent coronary computed tomography angiography (CCTA), which showed marked and diffuse calcified coronary plaques (calcium score, 2011 HU; >90th percentile for age) and severe stenosis in the proximal right coronary artery (RCA) (Figure 1A). He was referred to our catheterization laboratory for an elective coronary angiogram, which confirmed proximal and mid RCA stenoses ...

A 70-year-old man presented with lifestyle-limiting intermittent claudication (Rutherford stage III) affecting the right lower extremity. Physical examination of the right lower limb revealed weak distal pulses and a diminished ankle-brachial index of 0.6. Peripheral angiogram showed diffuse 80% stenosis over the right distal superficial femoral artery (SFA). The HawkOne directional atherectomy system (Medtronic Peripheral) was used to restore blood flow by removing plaque. After placing a 7 mm SpiderFX device (Medtronic Peripheral), optical coherence tomography (OCT) was acquired to assess baseline plaque load (Figure 1). Several runs of directional atherectomy were done. Angiogram and OCT were then obtained ...

A 32-year-old female with elevated body mass index and no prior medical history presented with acute-onset central chest pain radiating to both arms. Electrocardiogram showed biphasic T-waves in the anterior leads and troponin level was elevated. Echocardiogram demonstrated preserved left ventricular function and no valvular abnormality. A diagnosis of non-ST elevation myocardial infarction (NSTEMI) was made. Coronary angiography revealed a smooth tapering stenosis in the mid left anterior descending (LAD) artery (Video 1), but no significant disease beyond (Figure 1, top center panel). The other coronary vessels were free of significant disease. Given her age and the somewhat unusual angiographic ...

We present a case of follow-up optical coherence tomography (OCT) in a patient with non-obstructive intraluminal clot protrusion treated with medical therapy. The follow-up OCT scan showed layered neointimal changes similar to images observed in stent failure. A 37-year-old male presented with self-aborted anterior ST-elevation myocardial infarction. Urgent coronary angiogram showed thrombotic lesion in the proximal left anterior descending (LAD) artery (Figure 1). Multiple passes of aspiration thrombectomy retrieved a large amount of red thrombi. A drug-eluting stent was deployed in view of residual stenosis and clots (Figure 2, Video 1). Final OCT showed intraluminal clot protrusion at the proximal ...

A 37-year-old male presented with self-aborted anterior STEMI. Urgent coronary angiogram showed thrombotic lesion in the proximal LAD artery. Multiple passes of aspiration thrombectomy retrieved a large amount of red thrombi. The following angiogram and OCT series detail the patient’s treatment with a drug-eluting stent and 5-month follow-up results, which showed residual layered neointimal pattern at the proximal stent edge.

A 54-year-old man presented with non-ST elevation myocardial infarction. Coronary angiogram showed two-vessel disease with severe stenosis in the mid left anterior descending (LAD) artery and proximal and distal left circumflex (LCX) artery (Figure 1). Percutaneous coronary intervention (PCI) to the LCX was performed under optical coherence tomography (OCT) guidance. A 3 x 40 mm drug-eluting stent (DES) was implanted in the LCX, but landed more proximally than intended due to breathing motion. As a result, there was gross malapposition of the proximal stent as shown by OCT (Figure 2). To facilitate delivery of a 4 mm non-compliant balloon across ...

A 22-year-old, obese male smoker with untreated hyperlipidemia and family history of coronary artery disease presented with chest pain and ST-segment elevation in anterolateral leads at ECG following heavy marijuana and alcohol abuse. Coronary angiography showed a moderate stenosis in the proximal left anterior descending (LAD) coronary artery along with distal embolization (Figure 1A; Video 1). No concomitant coronary stenoses were noted, and TIMI 3 flow was present in the LAD. Optical coherence tomography (OCT) revealed plaque erosion with massive thrombi involving the distal left main coronary artery (LMCA) and ostial to mid LAD (Figure 1A; Video 2), along with ...

A 56-year-old male smoker with hypertension was admitted with lateral ST-elevation myocardial infarction. Coronariography showed a thrombotic occlusion of the circumflex artery (CX) solved with two overlapped drug-eluting stents. Multiple irregular linear filling defects and intraluminal haziness on proximal and mid left descending artery (LAD), mimicking a spontaneous dissection (Figure 1A and Video 1), were shown. Therefore, an optical coherence tomography (OCT) was performed on the LAD (Figure 1B and Video 2); OCT showed multiple small channels divided by thin septa communicating with each other in a “Swiss cheese” appearance, corresponding with a recanalization of organized thrombi. Upon re-interrogating the ...

A 49-year-old male smoker was admitted with chest pain and electrocardiographic T-wave inversion in the anterior chest leads and elevated levels of biomarkers of myocardial damage. Transthoracic echocardiography revealed anteroapical hypokinesis. Coronariography showed normal coronary arteries. Therefore, based on electrocardiographic and wall-motion abnormalities, we selected the left anterior descending artery as the cause of the acute coronary syndrome and coronary imaging was performed. Three-dimensional optical coherence tomography (3D-OCT) with angiographic co-registration was performed and an ulcerated small plaque covered by thrombus was observed (Figures 1-3; Videos 1-2). The amount of thrombus was not excessive and the minimal luminal area was ...

Background. Given its high resolution, optical coherence tomography (OCT) may be a useful clinical tool to optimize stent deployment. Methods. We reviewed 100 patients with post-PCI OCT who had angiographically optimized coronary stent implantation to determine the frequency of further intervention based on OCT pathology. OCT pathology was classified as “significant” if an OCT finding prompted further intervention. Results. OCT pathology was found in 90% of patients and considered significant in 52%. Stent strut malapposition by OCT was the most common reason for prompting further treatment, with approximately one-half due to relative stent undersizing. Based on OCT findings, 42% underwent ...

Abstract: Objectives. The purposes of this study were: (1) to assess the feasibility of optical coherence tomography (OCT) for detecting neovascularization; and (2) to clarify the impact of plaque neovascularization on coronary vessel behavior over time. Background. Plaque neovascularization may be related to plaque vulnerability. Methods. In an ex vivo study, a total of 55 coronary plaques from 31 human cadavers were examined by OCT. Plaque neovascularization was diagnosed based on the presence or absence of microchannels (MCs) by OCT. In an in vivo study, we explored 83 major coronary arteries from 42 patients with angina pectoris. A total of ...

Background. The impact of contrast type on coronary imaging using optical coherence tomography (OCT) has received limited study. We compared OCT imaging obtained using the non-ionic, iso-osmolar iodixanol with the ionic, low-osmolar ioxaglate. Methods. Twenty-two vessels in 20 patients were imaged twice using manual injection of iodixanol and ioxaglate in random order. OCT images were analyzed at 1 mm intervals to determine lumen area, artifact diameter and area, as well as stent strut coverage and malapposition in OCT pullbacks that included stents. Results. There were no complications related to OCT imaging or to contrast administration. A total of 2184 cross-sections ...

Coronary artery aneurysm with dissection is an uncommon presentation of Loeys-Dietz syndrome (LDS). Diagnosis and management of patients with LDS who present with unstable clinical syndromes merit special attention given unique pathophysiology derangements associated with this disease entity. Clinical experience in treating such patients is limited to a few case reports, and an optimal catheter-based treatment approach is less well defined. Intravascular imaging techniques, particularly optical coherence tomography (OCT), are able to provide further insight about the morphology of lesions and guide-catheter based intervention. In this case report, we describe one such patient and highlight the key morphological characteristics of ...