A new technique for lipid core plaque detection by optical coherence tomography for prevention of peri-procedural myocardial infarction: A case report

Abstract

Rationale: Percutaneous coronary intervention (PCI) provides effective revascularization of atherosclerotic coronary arteries but the invasive nature of treatment can result in complications.

Patient concerns: A 53-year old man underwent coronary angiography due to chest pain with minimal ST-segment elevation in the inferior leads of the electrocardiogram.

Diagnosis: We proceeded directly to coronary angiography and delineated a moderate stenosis with haziness in the mid right coronary artery (RCA).

Interventions: Expert analysis of the pre-intervention OCT imaging demonstrated a large lipid core plaque (LCP), upstream of the culprit site, with minimal thrombus burden. Subsequent implantation of a bioresorbable vascular scaffold, protected with distal deployment of a filter protection device provided an excellent result with retrieval of plaque material. Post-hoc attenuation analysis confirmed the presence of large LCP.

Outcomes: A post-procedural transthoracic echocardiogram confirmed good left ventricular function with no regional wall motion abnormality. An excellent clinical outcome was achieved.

Lessons: Optical coherence tomography (OCT) derived attenuation analysis can provide with qualitative and quantitative detailed evaluation of the underlying plaque substrate. Our case shows OCT can provide the interventionist with qualitative and qualitative assessment of large LCP for prevention of periprocedural complications, which may improve outcome for PCI.

Figure 1

(A and B) Angiographic assessment demonstrating a moderate stenosis, nonflow-limiting nature of the lesion, with haziness in the mid right coronary artery. (C) Poststent angiogram demonstrating filling defect within the distal protection device (arrow) (inset: macroscopic evidence of material in filter device). (D) Final angiogram demonstrating good distal flow without residual stenosis.

Figure 2

(A) Optical coherence tomography (OCT) assessment demonstrating minimal luminal area of 2.5 mm² with intraluminal thrombus (red points). (B1) OCT cross-section at the level of a small side branch demonstrating noncircumferential LCP (arrow heads delineate margins of the lipid core); (B2) post hoc analysis confirming the lipid rich nature of the plaque (between arrow both ways). (C1) Signal-poor and poorly delineated region, representing circumferential LCP; (C2) post hoc attenuation analysis demonstrating circumferential LCP (between arrow both ways). (D) A “carpet-view” attenuation vessel map demonstrating the large burden of LCP. Asterisk indicates wire artefact. LCP = lipid core plaque, OCT = optical coherence tomography, SB = side branch.