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Angioscopic findings during coronary angioplasty of coronary occlusions
F Alfonso1, J Goicolea, R Hernandez
1Cardiopulmonary Department, Hospital Universitario San Carlos, Madrid, Spain.
Insights
Coronary angioscopy reveals that most occluded vessels contain thrombus and plaque. Post-intervention, residual thrombus is often visualized, highlighting the need for tailored treatments.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Coronary angioscopy offers direct lumen visualization.
- Its utility in totally occluded coronary arteries during angioplasty is not well-established.
Purpose of the Study:
- To investigate angioscopic findings in totally occluded coronary vessels before and after intervention.
- To compare angioscopic findings with traditional angiography.
Main Methods:
- Coronary angioscopy was performed on 21 patients with totally occluded vessels before and after dilation.
- Occlusions were classified as functional (TIMI grade 1) or anatomic (TIMI grade 0).
Main Results:
- Before intervention, angioscopy identified thrombus (90%) or plaque (10%) as the occlusive material.
- After dilation, residual thrombus (89%) and dissections (72%) were frequently observed, often missed by angiography.
- Angioscopy detected silent distal embolization in one case.
Conclusions:
- Coronary angioscopy provides crucial details on the pathological substrate of occluded vessels.
- Thrombus associated with plaque is the primary cause of occlusion.
- Residual thrombus after intervention is common and may have prognostic implications, guiding treatment selection.
Objectives:
This study sought to elucidate angioscopic findings in totally occluded vessels before and after intervention.
Background:
Coronary angioscopy allows direct visualization of the lumen surface of the coronary arteries; however, the utility of coronary angioscopy during coronary angioplasty of vessels with a total occlusion is unknown.
Methods:
Twenty-one consecutive patients (mean [+/- SD] 58 +/- 9 years, range 39 to 77; 3 women, 18 men) undergoing dilation of an occluded vessel were studied with coronary angioscopy. Occlusions were classified as functional in 8 patients (Thrombolysis in Myocardial Infarction [TIMI] flow grade 1) and anatomic in 13 (TIMI flow grade 0). Once the guide wire had crossed the occlusion, coronary angioscopy was attempted before and after angioplasty.
Results:
In all patients, coronary angioscopy before dilation visualized protruding material occluding the coronary lumen where the guide wire was wedged. The occlusion consisted of red thrombus in 19 patients (90%) (2 with isolated occlusive thrombus, 17 with thrombus associated with atherosclerotic plaque) and protruding yellow plaque in 2 patients (10%). However, on angiography only 7 occlusions (33%) had data consistent with thrombus (p < 0.01 vs. coronary angioscopy). Successful dilation was obtained in 20 patients. After dilation, coronary angioscopy was repeated in 18 patients, revealing residual thrombus with plaque in 16 (89%) and a residual yellow plaque in 2. In addition, coronary angioscopy revealed coronary dissections in 13 patients (72%); however, angiography revealed dissections only in 10 patients (55%) and residual thrombus in 2 (10%) (p < 0.001). In one patient, coronary angioscopy visualized silent distal embolization of a red thrombus not previously recognized on angiography.
Conclusions:
Before intervention, coronary angioscopy provides unique insights into the pathologic substrate of occluded coronary vessels. An occlusive plaque with thrombus is the most common underlying substrate in these lesions. After successful dilation, angiographically silent mural thrombus is seen in most patients. This information could be used to assist in the selection of candidates and type of coronary interventions and could also prove to be of prognostic value in patients with occluded vessels.