Drug-resistant vasospastic angina pectoris with plaque erosion in the focal spastic lesion confirmed with coronary angioscopy

Abstract

DESCRIPTIONPlaque erosion within the coronary artery accounts for up to 20% of all sudden deaths and up to 40% of sudden deaths as a result of coronary thrombi in patients with coronary artery atherosclerosis.1 2We present a case of drug-resistant vasospastic angina pectoris (VSA) with erosion in the focal spastic lesion confirmed with coronary angioscopy (figure 1). A 78-year-old man presented to the coronary care unit with sudden chest pain accompanied by ECG ST segment elevation on V1-V3 and elevation of serum troponin-T level. A coronary angiography (CAG) revealed 90% stenosis in segment 2 of the right coronary artery, and this was removed by an intra-arterial injection of nitroglycerin. The left coronary artery was normal. Based on the above findings, acute coronary syndrome (ACS) associated with VSA was diagnosed. One month later, the patient was readmitted for ACS. CAG showed no stenosis, and an acetylcholine provocation test was performed in conjunction with adequate medication therapy (videos 1 and 2). As a result, focal vasospasm was induced, with the patient experiencing chest pain and an ECG change at segment 2 (figure 2). Coronary angioscopy showed yellow plaque with erosion at segment 2, similar to that of ACS (video 3 and figure 3). Percutaneous coronary intervention (PCI) was performed in this segment using a bare metal stent in conjunction with drug therapy. The PCI was successful, and the patient no longer experienced chest pain or ACS recurrence. This is the first case in which intimal injury of a focal spastic lesion has been confirmed by coronary angioscopy in a case of ACS. Pathological intimal injury has been previously observed in VSA, 1 and a causal relationship has been reported between intimal injuries (such as haemorrhage, flap, thrombusor ulcer) and VSA. These factors have not been previously reported in the context of ACS. PCI is a controversial method of treatment for VSA. While some case reports have shown the therapeutic validity of stent placement for drug-resistant focal VSA, 3 other reports have described provocation of vasospasm at the stent edge following this procedure. The influence of the stent in these cases-particularly the drug-eluting stent-was unclear. In this case, while the coronary artery stenosis was treated, we chose to supplement this treatment with PCI with a bare metal stent. As a result of this treatment, the VSA did not recur and was not provoked by follow-up acetylcholine stress testing after PCI.In conclusion, the case presented here elucidates the mechanism underlying intractable focal drugresistant VSA and provides evidence of a possible therapy for this condition.

What's happening in carotid stent? A case report of prominent plaque protrusion after carotid artery stenting observed on angioscopy

“…Angioscopy is a common tool in coronary interventions used for plaque study, 8,9 to observe intimal healing processes after stenting, 10,11 and for end‐procedural imaging 12,13 . The application of angioscopy in carotid intervention was first reported by Tanemura et al, 14 who described findings, only on photos, such as ruptured fibrous cap, clots, and debris in 18 carotid interventions only on photos.…”