Optical coherence tomography-guided deferred stenting in acute coronary syndromes

Immaneni Sathyamurthy; Srinivasan Narayanamoorthy Kanthallu; Vinodh Kumar Paulpandi

doi:10.4103/jicc.jicc_87_20

CASE REPORT

Year : 2022 | Volume : 12 | Issue : 1 | Page : 37-39

Optical coherence tomography-guided deferred stenting in acute coronary syndromes

Immaneni Sathyamurthy, Srinivasan Narayanamoorthy Kanthallu, Vinodh Kumar Paulpandi
Department of Cardiology, Apollo Main Hospitals, Chennai, Tamil Nadu, India

Date of Submission	30-Dec-2020
Date of Decision	16-Feb-2021
Date of Acceptance	07-Apr-2021
Date of Web Publication	08-Feb-2022

Correspondence Address:
Dr. Immaneni Sathyamurthy
Department of Cardiology, Apollo Main Hospitals, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicc.jicc_87_20

Abstract

Acute coronary syndromes were thought to be due to plaque rupture with superimposed thrombus. With optical coherence tomography plaque erosion (PE) can be detected in one third of cases. In young patients without major risk factors one can suspect PE. We are reporting one such case in whom stenting was deferred.

Keywords: Acute coronary syndromes, deferred stenting, optical coherence tomography, plaque erosion

How to cite this article:
Sathyamurthy I, Kanthallu SN, Paulpandi VK. Optical coherence tomography-guided deferred stenting in acute coronary syndromes. J Indian coll cardiol 2022;12:37-9

How to cite this URL:
Sathyamurthy I, Kanthallu SN, Paulpandi VK. Optical coherence tomography-guided deferred stenting in acute coronary syndromes. J Indian coll cardiol [serial online] 2022 [cited 2022 May 27];12:37-9. Available from: https://www.joicc.org/text.asp?2022/12/1/37/337357

Introduction

Acute coronary syndromes (ACS) were thought to be due to thrombosis over a plaque rupture (PR). With the introduction of optical coherence tomography (OCT) imaging, it became evident that ACS can be due to PR, plaque erosion (PE) or rarely due to thrombus over a protruding calcium nodule (CN). After the publication of erosion study,^[1] it opened up new avenues to treat selected cases of PE conservatively without stenting. Lot of new information is evident from the latest publications^[2],[3] regarding prediction, accurate diagnosis and selection of cases for OCT during primary percutaneous coronary interventions. We are reporting a young male with ACS where stenting was deferred after OCT confirmation.

Case Report

A 30-year-old male experienced severe retrosternal chest discomfort with diaphoresis at 3 AM, but reported to emergency 4 h later. On admission, he was free from symptoms, pulse, BP, electrocardiogram, and echocardiograms were normal. Hs trop I was elevated (0.86 pgm/ml). There was no history of diabetes, hypertension, smoking, or family history of premature coronary artery disease. His BMI was 35.6, mildly elevated low density lipoprotein-cholesterol levels. He was diagnosed as non-ST elevation myocardial infarction (NSTEMI). Coronary angiogram (CAG) revealed mild ectasia of proximal left anterior descending (LAD) with a thrombus astride origin of thin D2 with TIMI 3 flow [Figure 1]a. The left circumflex and right coronary arteries were normal.

Figure 1: (a) Coronary angiogram at admission showing mild ectasia of LAD, arrow showing luminal thrombus astride the origin of D2. (b) Repeat coronary angiogram 48 h after GP IIb/IIIa inhibitor infusion, arrow showing persistence of thrombus. (c) Repeat coronary angiogram at 6 months' follow-up showing disappearance of thrombus

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He was given weight adjusted eptifibatide infusion for 48 h along with ticagrelor, aspirin, and atorvastatin. He remained asymptomatic and repeat CAG after 48 h revealed persistence of intracoronary thrombus with TIMI 3 flow [Figure 1]b. OCT revealed a white thrombus attached to the intima [Figure 2]a and at the proximal edge of the thrombus a subintimal PE was detected with intact media [Figure 2]b and [Figure 2]c. There was no evidence of lipid-rich necrotic plaque, ulceration, or rupture ruling out the possibility of PR. As he was asymptomatic with TIMI 3 flow stenting was deferred and he was continued on conservative treatment with antiplatelets and statins.

Figure 2: (a) Initial optical coherence tomography done 48 h after GP IIb/III an inhibitor infusion showing a white thrombus at 8' o clock position over a preserved vascular structure. (b) Optical coherence tomography showing plaque erosion at 7'o clock position. (c) Zoom image of optical coherence tomography showing plaque erosion

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He remained asymptomatic and active during 6 months follow-up, when treadmill test was negative at 13 mets load. Repeat CAG showed disappearance of thrombus in LAD with TIMI 3 flow [Figure 1]c. Repeat OCT showed uninterrupted, irregular intima without thrombus revealing a healed PE [Figure 3]. At the end of 1 year, he remained asymptomatic with a negative stress test. This case showed the possibility of conservative management in cases of ACS due to PE when confirmed by OCT.

Figure 3: Optical coherence tomography at 6 months' follow-up showing healed plaque erosion between 7 and 8' o clock position. The intima is intact, irregular without any thrombus

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Discussion

ACS were thought to be due to thrombus over a PR. Virmani et al.^[4] reported their autopsy series of 200 cases of sudden cardiac death in whom only one-third of cases were found to have PR. With the introduction of OCT, three types of in vivo lesion morphologies responsible for ACS were recognized, PR being the most common followed by PE and CN being least common. In various studies, PE was found to be responsible for ACS in 30%–40% cases.^[5] Superimposed thrombus makes OCT confirmation difficult but GP IIb/IIIa inhibitors may facilitate lysis of the clot to enable proper recognition of underlying plaque morphology.

Our patient received eptifibatide for 48 h before CAG was repeated and OCT confirmed the presence of PE. Our case was a young male without major risk factors presented as NSTEMI with TIMI 3 flow on CAG. Approximately two-thirds of patients of PE were found to manifest as NSTEMI.^[5] Erosion study^[1] was a prospective study where 25% of cases revealed PE by OCT in whom stenting was avoided.

As our patient was stable with TIMI 3 flow, we have decided to defer stenting and continue on conservative treatment. At the end of 6 months, when the CAG was repeated, thrombus disappeared and PE healed as confirmed by OCT. Since there was TIMI 3 flow, thrombus aspiration was not attempted in our case to avoid risk of distal embolization. TOTAL study^[6] substantiated that thrombus aspiration may add to the risk of distal embolization and strokes and may even alter the plaque morphology. Souteyrand et al.^[7] reported large thrombus burden in 80% of their cases. They adopted two-step revscularization approach with optimal reperfusion followed by delayed angiography and OCT and when the PR was absent with <70% stenosis of culprit artery, stenting was avoided. Of the 23 patients only 2 who presented with recurrence of angina needed stenting at 6 months. This confirms that stenting can be deferred in cases of ACS due to PE in selected cases as is evident from our case.

Yonetsu et al.^[8] attempted to predict PE clinically by identifying risk variables such as age <68 years, anterior ischemia, Hb% >15 gm%, absence of diabetes, normal renal functions and showed a predictive value of 73%. Dai et al.^[9] in their series of 209 cases found PE to be more common in premenopausal women, current smokers with fewer risk factors and noted PE frequently at bifurcation points as was observed in our case. In young patients of NSTEMI without major risk factors one can clinically suspect PE and plan OCT while doing CAG.

Although PE was reported in various studies, we were fortunate enough to detect by OCT and could defer stenting in a thrombus containing lesion to avoid the risk of distal embolization and stent thrombosis. The detection of PE in cases of ACS needs wide index of suspicion and OCT is the key to diagnosis. There is a need for large scale randomized trials in cases of ACS due to PR and PE comparing conservative with interventional management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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