Recanalized thrombus

Optical coherence tomography imaging of recanalized thrombus

A 76-year-old man with chronic kidney disease was referred to outpatient department of Chonnam National University Hospital for suffering from aggravating effort angina. After treatment with aspirin (300 mg loading dose) and clopidogrel (300 mg loading dose), coronary angiography (CAG) was tried via left distal radial artery due to as a preservation of radial artery for arteriovenous (AV) fistula creation. However, anomalous brachial artery led to change access site into right snuffbox approach (Fig 1A). CAG demonstrated the diffuse stenosis with multiple linear filling defects and haziness in the proximal right coronary artery (RCA) (Fig. 1B). Optical coherence tomography (OCT) showed honeycomb-like structure with multiple cavities and we concluded that this appearance represented recanalized thrombus (Fig. 1C, D). OCT assessment led to implantation of a 2.75 × 38 mm Xience Sierra stent (Abbott Vascular, Santa Clara, CA, USA) and postdilation was achieved with a 3.25 × 12 mm noncomplicant balloon up to 21 atm in the proximal portion of implanted stent. Repeated OCT assessment demonstrated good stent expansion and strut apposition without edge dissection. Final CAG showed good distal flow without residual stenosis (Fig. 1E).

This case highlights that OCT enables to confirm a rare case of the recanalized thrombus and snuffbox approach can be an alternative access site in patients with renal impairment who need to protect radial artery for AV fistula.

Fig. 1. (A) Peripheral angiography demonstrating anomalous left brachial artery. (B) Coronary angiography demonstrating multiple linear filling defects and haziness in the proximal right coronary artery. (C and D) Longitudinal and cross-sectional OCT image demonstrating honeycomb-like structure with multiple cavities of various sizes. (E) Final coronary angiography demonstrating good distal flow without residual stenosis after deployment of 2.75 × 38 mm Xience Sierra® stent.

References

1. Kim Y, Jeong MH, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y. Multivessel Disease With Recanalized Thrombus - Etiologic Insights From Optical Coherence Tomography. Circ J 2019;83:688.
2. Image of a chronic recanalized thrombus by intracoronary imaging: intravascular ultrasound and optical coherence tomography analysis. Estévez-Loureiro R, Calviño-Santos R, Salgado-Fernández J, López-Sainz A, García-Guimaraes M, Piñón-Esteban P, Aldama-López G, Vazquez-Gonzalez N, Castro-Beiras A. JACC Cardiovasc Interv 2012;5:e33-4.