Abstract

Background: Atherosclerosis is a dynamic process that begins early in childhood, with a slow progression that makes acute coronary syndrome an unusual entity in young people. Undetected ambulatory necrosis in young subjects may lead to an inappropriate decision in coronary angiography management. The aim of our case report is to highlight the importance of endo-coronary imaging in the management of coronary artery disease. Case Presentation: We report on the case of a young patient of 43 years old scheduled for a diagnostic coronary angiography due to a modified electrocardiogram. As the coronary appearance was in favor of spontaneous dissection of the left anterior descending artery, endocoronary imaging by optical coherence tomography was performed, highlighting an appearance of LOTUS ROOT. This has made it possible to adapt the therapeutic care. Conclusion: This case highlights the importance of endocoronary imaging in the management of ambiguity in angiocoronary imaging.

Keywords

Lotus Root, Optical Coherence Tomography, Angioplasty

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1. Introduction

The presence of several lumens inside a coronary artery is the consequence of a recanalization of this artery or neovascularization of a thrombus [1] [2]. This aspect has a lotus root-like appearance and is diagnosed through endocoronary imaging. Several studies carried out using Optical Coherence Tomography (OCT) to understand this specific aspect are in favor of spontaneous recanalization of an intracoronary thrombus [2]-[5]. Given the absence of angiocoronarographic presumption, endocoronary imaging should be used in cases of suspicious images of incomprehensible mechanisms. Several authors have proposed drug-eluting stenting for this condition, with good results.

2. Clinical Case

We report the case of a young 43-year-old patient referred by his attending cardiologist for diagnostic coronary angiography in view of electrocardiographic abnormalities such as Q waves from V2 to V5, ST segment elevation from V1 to V3, and apicolateral subepicardial ischemia (Figure 1). His only cardiovascular risk factor was active smoking. Seven months previously, he had presented with anginal chest pain for which he had not sought medical attention.

Figure 1. Electrocardiogram showing repolarization disorders.

Upon admission, the patient’s only complaint was exertional dyspnea. The clinical examination did not reveal any signs of left or right congestion, and the hemodynamic status was satisfactory. Biologically, renal function was normal with a creatinine clearance according to CKD-EPI of 105 and troponins of 31.5 pg/ml (normal = 0.0 - 14.0 pg/ml). LDL cholesterol was 0.59 g/l and triglycerides were 0.63 g/l. Hemoglobin level was 14.2 g/dl.

Coronary angiography performed via the right radial approach (6F) revealed a “phasme” appearance on the Left Anterior Descending artery (LAD) (Figure 2), suggesting spontaneous coronary dissection. Using a LAUNCHER EBU 3.5 6F 100 cm guiding catheter and a SION Blue 0.014 J 190 cm guidewire, endocoronary imaging by OCT was performed in front of this “phasme” appearance. The OCT revealed several long intracoronary lumens running the length of the LAD, giving a “lotus root” appearance (Figure 3). The lesion was pre-dilated with a non-compliant PIPIT 2.5 × 30 mm balloon and then treated with an everolimus-coated active stent (XIENCE Skypoint 2.5 × 48 mm). OCT-guided optimization was performed with a PIPIT 3.75 × 8 mm non-compliant balloon in the proximal part of the stent, followed by a PIPIT 3.0 × 20 mm non-compliant balloon in the middle part of the stent. The distal part of the stent had not been optimized because the size of the chosen stent matched the size of the distal part of the lesion. The final result was good (Figure 4).

Figure 2. “Phasme” appearance on the LAD.

Figure 3. “Lotus root” appearance on the LAD.

Figure 4. Final result after stenting.

3. Discussion

The intracoronary lotus root-like appearance is characterized by the presence of multiple lumens separated from each other by partitions, communicating with each other and converging into a single lumen proximally and distally [2] [6]. Its diagnosis is based on endocoronary imaging.

Figure 5. Therapeutic algorithm for SCAD management. [8]

In our case, seven months prior to the coronary angiography, the patient presented with angina-like chest pain which he had neglected. A posteriori, we can conclude that this pain was related to an occlusion of the LAD. By unknown mechanisms, recanalization of the occluded LAD had occurred, resulting in the genesis of multiple intracoronary lumens. Although rare, it’s important not to overlook the fact that coronary occlusion can occur in young people, leading to acute coronary syndromes, especially if the latter are smokers, have dyslipidemia or have inherited coronary artery disease [7]. In our case, the initial therapeutic approach of the interventional cardiologist, given our patient’s age, the correct hemodynamic state and TIMI 3 flow on coronary angiography would be medical treatment, which is the treatment for spontaneous coronary dissections. Management of spontaneous coronary dissections is essentially conservative, except in rare cases where revascularization treatment is indicated [8]. (Figure 5)

However, OCT endocoronary imaging revealed a “lotus root” appearance, which was treated with a Drug Eluting STENT (DES). In the literature, several authors have proposed various treatments for this lotus root aspect, namely either treatment with DES, treatment with drug-coated balloons, or treatment with bioabsorbable stents or stent grafts [9]-[11]. This technique, decisive for the management of our patient, has once again demonstrated its added value in ambiguous cases, as shown by several authors [12]-[14]. This highlights the importance of endocoronary imaging in the management of coronary patients in general, young patients in particular. In addition to helping diagnose the “lotus root” appearance, OCT imaging enabled us to guide angioplasty by choosing the right stent length, the right stent size, the right balloon size for stent staged optimization and, finally, to verify correct stent deployment and apposition.

The particularity of this case lies in the therapeutic attitude of the angioplastician, who had initially opted for conservative treatment. The added value of Endo coronary imaging and the unusual appearance of the LOTUS ROOT changed management. In the absence of cardiovascular imaging, conservative treatment would have been performed, which would have altered the patient’s prognosis.

One question that remains unanswered is why some people develop these neo vessels after coronary artery occlusion and others do not. Further studies are needed to identify the various factors that can be used as therapeutic means in the management of coronary pathologies

4. Conclusion

This clinical case highlights the importance of endocoronary imaging in the management of coronary artery disease. It is always useful to use the various means available to improve patient management. As atherosclerosis is a dynamic phenomenon, the wrong therapeutic decision will have consequences in the short to medium term.

Take Home Messages

This case highlights the importance of endocoronary imaging in the management of ambiguity in angiocoronary imaging.

Consent

The authors confirm that oral consent for submission and publication of this case report including images and associated text has been obtained from the patient.

Abbreviations

Appendix

Vidéo 1: https://docs.google.com/videos/d/1jIrbwrEfEGADKDTSQlcHbSQ1X0lAhKebp7RlukezQhw/edit?usp=sharing

Vidéo 2: https://docs.google.com/videos/d/1VZ3ZA3N_EuY4x94EVXn4Bj5WJJOOvfsDV7DOVWLnFr4/edit?usp=sharing

Vidéo 3: https://docs.google.com/videos/d/1LWAO903HuCBVGHGsuKULHgIG3y5NezpOFSNs42Y0P44/edit?usp=sharing

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References