NM

A 42y.o lady who is 4 weeks post-partum presented with sudden onset typical chest pain at rest not resolving with sublingual GTN. She is known diabetic with very high-risk pregnancy due to pre-existing IHD under a different center follow-up and has been uneventful to date. She had history of inferior MI 2 years ago where she underwent percutaneous coronary intervention with DOAC+DAPT for 6months and DOAC+SAPT for 6months. She is only on aspirin and bisoprolol throughout pregnancy.

We managed to trace her previous angiogram done 2 years ago (24/12/20) which showed thrombus in RCA with diffusely ectatic and atherosclerotic RCA,LCx and LAD disease. A conservative approach with POBA to RCA and anticoagulants were used back then to manage her coronary artery disease. Her ECHO at 36weeks gestation showed LVEF 50% with no regional wall motion abnormalities.
22/6/22Serial ECG: Deepening T inv III,aVFTroponin I : 14300pg/mLECHO : LVEF 45% with hypokinesia basal to mid inferior wall

Urgent coronary angiogram were carried out in view of very high risk NSTEMI (persistent chest pain, dynamic ECG changes with very high Troponin). Coronary angiogram showed diffusely ectatic and atherosclerotic RCA,LCx and LAD disease. There is a woven-like appearance of proximal to mid RCA with intraluminal haziness and stenotic lesion at distal RCA.

Intraluminal haziness from the angiogram is likely to be thrombus in this setting but spontaneous coronary artery dissection and ruptured plaque can be other highly likely possibilities. Thus, intravascular ultrasound (OptiCross HD, Boston Scientific) is used to ascertain the morphology and to determine the ectatic vessel size for PCI optimization. IVUS showed multiple cavities and septations with blood speckling in the proximal to mid RCA corresponding with intraluminal haziness seen in the angiogram. Correlating the previous and current coronary angiogram with the IVUS images, these findings are consistent with previous chronic thrombotic coronary artery occlusion, which recanalized forming multiple lumens. In view of the heavy burden of chronic recanalized thrombus, we performed multiple runs of thrombus aspiration with CAT Rx Aspiration Catheter Indigo System, Penumbra prior to lesion preparation. Synergy DES 4.0x48mm was deployed from proximal to mid RCA. IVUS guided stent optimization were done with NC Emerge 5.0mm at proximal and distal stent segment and NC Emerge 6.0mm high pressure at mid stent segment. MagicTouch DCB 3.0 x 24mm was deployed at distal RCA stenotic segment. Final IVUS showed slightly malapposed stent at the largest aneurysmal segment (mid stent segment) with good stent apposition elsewhere and results accepted. She is discharged well with triple therapy (DOAC+DAPT).

Angiographically hazy coronary lesions are non-specific. Multiple linear filling defects are commonly described angiogram finding in coronary dissections but as shown in our case they can be the result of a chronic recanalized thrombus. Recanalized thrombus of coronary arteries is an under-recognized entity. Intravascular imaging conclusively establishes its diagnosis, which otherwise is often misdiagnosed as fresh thrombus, spontaneous coronary artery dissection, or severe calcification based on angiography alone.