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Published on: May 28, 2019
No-reflow following dilatation of a coronary lesion with a large lipid core
Jun-ichi Kotani1, Shinsuke Nanto, Masafumi Kitakaze
1Cardiovascular Division, Kansai Rosai Hospital, Amagasaki, Japan.
Insights
Radiolucent coronary angiogram findings can indicate atheromatous plaque, not just thrombus. Mechanical disruption of lipid-rich plaque during angioplasty can cause sudden flow reduction.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Pathology
Background:
- Coronary angiogram radiolucent lesions are typically attributed to intracoronary thrombus.
- Acute myocardial infarction necessitates prompt restoration of coronary blood flow.
Observation:
- A 62-year-old male presented with inferior acute myocardial infarction and TIMI-1 flow in the right coronary artery.
- Initial thrombectomy improved flow to TIMI-2, but a persistent radiolucent lesion remained.
- Mechanical dilatation of the lesion led to abrupt flow cessation (TIMI-0, no-reflow).
Findings:
- Aspiration of the lesion yielded atheromatous gruel, including macrophages (foam cells) and cholesterol crystals.
- The radiolucent lesion was identified as an atheromatous plaque with a large lipid core.
- Mechanical disruption of this plaque during angioplasty caused the sudden flow reduction.
Implications:
- Challenges the assumption that radiolucent coronary lesions are solely thrombotic.
- Highlights the potential for atheromatous plaque disruption during interventional procedures.
- Suggests aspiration of atheromatous material as a treatment for no-reflow following plaque manipulation.
Abstract:
Radiolucent findings of coronary angiogram are believed to usually represent intracoronary thrombus, but in the present case, were atheromatous plaque with a large lipid core. A 62-year-old man who suffered from an inferior acute myocardial infarction was admitted to hospital 6 h after onset. The first cine angiograms showed TIMI-1 flow in the distal-portion of the right coronary artery, so thrombectomy was initially carried out and TIMI-2 flow achieved. However, the radiolucent lesion did not disappear and so adjunctive mechanical dilatation of the lesion was prformed, which resulted in 'no-reflow' (TIMI-0). Finally, aspiration of the material from the stagnated lesion was attempted and immediately obtained TIMI-3 flow. The retrieved materials were macrophages (foam cells) and many cholesterol crystals, both of which are considered to be atheromatous gruel. Therefore, the sudden flow reduction following percutaneous transluminal coronary angioplasty was caused by mechanical disruption of an atheromatous plaque with a large lipid core.
