No abstract

Background/Aim: Spontaneous recanalization of coronary thrombus (SRCT) is a rare in vivo appearance, with a nonspecific angiographic aspect. The aim of this study was to investigate the importance of optical coherence tomography (OCT) use for SRCT identification, characterization of pathogenic mechanisms and optimal treatment. Patients and Methods: We retrospectively analyzed all patients with angiographic suspicion of SRCT who underwent coronary angiography for suspected coronary artery disease and afterward investigated by OCT imaging. Results: We identified 28 cases with angiographic suspicion of SCRT (0.41% of CA) and confirmed it in 4 patients (0.05% of CA). OCT provided insight about the underlying SRCT mechanism: possible complicated atherosclerotic plaques in two cases and, respectively, spontaneous coronary artery dissection in other two cases. OCT provided accurate lesion assessment and offered optimal PCI materials selection. Conclusion: Besides providing the diagnosis, OCT also improved characterization of SRCT pathogenic mechanisms, in the four confirmed SRCT cases, supporting the role of coronary wall in situ complications, namely dissection of an atherosclerotic plaque or spontaneous dissection of a normal coronary wall.

This review treats antithrombotic use for peripheral arterial disease (PAD). In asymptomatic patients, there are no scientific data to support single antiplatelet therapy (SAPT) for primary prophylaxis. In symptomatic PAD, SAPT with aspirin or clopidogrel is indicated. The efficacy of aspirin is controversial. Clopidogrel may be preferred over aspirin. Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but lowers the risk of ischaemic stroke. In symptomatic PAD, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding. DAPT with ticagrelor 60 mg b. i. d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of SAPT or DAPT with aspirin and/or clopidogrel, reduces the risk of acute limb ischaemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints - total mortality and cardiovascular mortality. Therefore, this association shows the strongest evidence for secondary prevention of symptomatic PAD patients. In PAD patients undergoing percutaneous peripheral interventions, at least four weeks of DAPT with aspirin and clopidogrel is recommended after infrainguinal stent implantation. Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available. Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures. The strategy includes use of unfractioned heparin, bivalirudin or enoxaparin. Vitamin K antagonists may be considered after autologous vein infrainguinal bypass.

Peripheral artery disease (PAD) increases the risk of diabetes, while diabetes increases the risk of PAD, and certain symptoms in each disease increase the risk of contracting the other. This review aims to shed light on this harmful interplay between the two disorders, with an emphasis on the phenotype of a patient with both diabetes and PAD, and whether treatment should be individualized in this high-risk population. In addition, current guideline recommendations for the treatment of PAD were analyzed, in an attempt to establish the differences and evidence gaps across a population suffering from these two interconnected disorders.

Background: The aim of this study was to evaluate the benefit of standard practice Optical Coherence Tomography (OCT) imaging, as a complement to coronary angiography (CA), for optimizing the indications, strategy, and results of percutaneous coronary interventions (PCI). Methods: We retrospectively analyzed 182 patients with OCT imaging in a single tertiary center. Results: OCT use had a low prevalence (3.1% of 4256 CAs and 1.7% of 3027 PCIs). OCT was used post-CA in 71.5% and post-PCI in 28.5% of cases, mainly in acute coronary syndromes—95.6%. OCT was performed for borderline lesions in 43.4% of cases; lesion severity was reassessed as severe and led to PCI in 64.5% of them. OCT was performed for nonsignificant lesions in 17% of cases; lesion severity was reassessed as severe and led to PCI in 38.7% of them. OCT provided optimal selection for PCI strategy in 11% of cases. OCT identified suboptimal PCI results in 54% left main PCIs and in 48% bifurcation PCIs with optimal CA; PCI optimization was performed. In the only seven patients with suboptimal PCI, OCT revealed an optimal result in four cases, thus avoiding unneccessary optimization. In 27.3% of patients with post-CA OCT and PCI result “systematic” OCT control, a PCI optimization was indicated. Conclusion: OCT supplied a major benefit in 86.2% of cases, especially by identifying significant coroanry stenosis in CA borderline and nonsignificant lesions; OCT led to PCI indication in two-thirds and, respectively, one-third of these cases. In the post-PCI context, OCT led to an indication of PCI optimization in half of the complex left main and bifurcation lesions, as well as in a quarter of “systematic” post-PCI OCT controls.

Cardiovascular diseases are the main cause of death worldwide, with coronary artery disease being the predominant underlying etiology. The most prevalent coronary lesions are represented by the atherosclerotic plaques, in more than 85% of cases, but there are several other non-atherosclerotic lesions such as spontaneous coronary artery dissection and/or hematoma and spontaneous recanalization of coronary thrombus, which are less common, approximately 5% of cases, but with similar clinical manifestations as well as complications. There are insufficient data regarding the pathological mechanism, true prevalence and optimal treatment of these kind of coronary lesions. Optical coherence tomography (OCT) is an intracoronary imaging technique, developed in order to overcome the diagnostic limitations of a standard coronary angiography and has an extremely high resolution, similar to that of a usual histological evaluation of a biopsy sample, thus, OCT provides a histological-like information, but in a in vivo environment. The aim of this article is to review the current knowledge regarding non-atherosclerotic coronary lesions, with an emphasis on the importance of OCT for optimal identification, characterization of pathogenic mechanisms and optimal treatment selection.

A premenopausal 47-year-old female, with no significant cardiovascular risk factors, was admitted 3 h after the onset of an inferior ST-segment elevation myocardial infarction. Emergency coronary angiography and optical coherence tomography (OCT) imaging revealed a long, spiral, spontaneous coronary dissection (SCAD) of the right coronary artery (

A 40-year-old male, without cardiovascular risk factors, was referred to our unit from another hospital at 4 h after anterolateral ST-segment elevation myocardial infarction (STEMI) onset (1 mm in DI and aVL and 2 mm in V2-V4) ( Fig. 1-B1). Severe anterolateral hypokinesia was present on echocardiography. Cardiac necrosis was confirmed by troponin I (TnI) increase (7.8 ng/mL), and later by peak creatinine kinase (CK; 762 IU/L) and CK-MB (63 IU/L). Emergency coronary angiography was performed. Left anterior descending artery (LAD) flow was TIMI 1-2 at first injection and TIMI 3 thereafter, with normal coronary walls ( Fig. 1-A1, A2). LAD imaging, using optical frequency domain imaging (optical coherence tomography [OCT]) (St. Jude Medical, St. Paul, Minnesota, USA), was performed, revealing a proximal LAD plaque with intra-plaque dissection and haematoma, induced by vasa vasorum haemorrhage and possibly stabilised by intimal tear decompression (Fig. 1C, D, E). Conservative treatment was decided upon. Electrocardiogram (ECG) evolution suggested reperfusion ( Fig. 1-B2). The ECG later normalised ( Fig. 1-B3). The patient was discharged 7 days later and has remained asymptomatic for the past 12 months. Coronary artery dissection or haematoma were previously correlated to important angiographic abnormalities, while our case presented with nearly normal angiography, except for the LAD flow impairment at the first injection. Before angiography and in-wall haematoma decompression, flow impairment may have been worse, due to greater lumen compression. Contrast injection during angiography may have also acted as a coronary vasodilator, thus explaining the improvement of coronary flow. OCT imaging in this patient draws attention to a particular STEMI pathophysiology, namely vasa vasorum haemorrhage ( Fig. 1-C1-C5). Of particular interest is the fact that OCT imaging revealed a connection between vasa vasorum, coronary dissection, intramural haematoma and, respectively, LAD lumen. Vasa vasorum traject could extend to the coronary lumen, but there is also the possibility that decompression of in-wall haematoma, through an intimal tear, may have been the mechanism of stabilisation for this patient. OCT imaging provided the diagnosis of coronary dissection and haematoma in this STEMI patient with nearly normal angiography and gave insight into the mechanisms related to the pathogenesis and, possibly, stabilisation of a coronary dissection.