Multiple recanalized images of thrombotic occlusion 19 years after percutaneouscoronary intervention: Insights from optical coherence tomography andintravascular ultrasound

Shinichiro Sakurai, Hiroaki Takashima ⁎, Katsuhisa Waseda, Hirohiko Ando, Akiyoshi Kurita, Tetsuya AmanoDepartment of Cardiology, Aichi Medical University, Japan

a r t i c l e i n f o

Article history:Received 24 October 2013Received in revised form 28 December 2013Accepted 1 January 2014Available online 22 January 2014

Keywords:Lotus root-like appearanceRestenosisOptical coherence tomographyIntravascular ultrasoundPercutaneous coronary intervention

A 74-year-old manwith hypertension, dyslipidemia, and diabetesmellitus had undergone percutaneous coronary intervention to theright coronary artery (RCA) because of exertional angina pectoris inMay 1994. At that procedure, coronary dissection had occurred fromthe middle to the distal segment of the RCA and 2 bare metal stents(Palmaz-Schatz) were implanted at the distal RCA. After thisprocedure, he had relief from his anginal symptoms. However, inApril 2012, he revisited our hospital due to worsening exertionangina symptoms. Stress electrocardiogram and stress myocardialscintigraphy performed at that time suggested inferior myocardialischemia. Coronary angiography showed two separated severestenosis sites with a braid-like appearance at the middle and distalsegments of the RCA (Fig. 1A and B). Optical coherence tomography(OCT) and intravascular ultrasound (IVUS) images revealed that twoseparated lesion sites were independently composed of multiplechannels which were communicating with each other. These lesion

sites converged into a single lumen in the proximal and distal site(Fig. 2, Movies 1 and 2).

Previous reports showed that these lotus root-like appearanceswere considered a recanalized image of thrombotic occlusion [1,2].However, previous reportsmentioned only a continuous single lesionsite. These two separated recanalized thrombotic occlusion imageswere considered to derive from different mechanisms. At the middlesegment of RCA, OCT and IVUS images showed vascular enlargementwithout a part of media, suggesting that major coronary dissectionand the stagnation of blood flow were the cause of thromboticocclusion. On the other hand, normal vessel wall components wereobserved at stented segments of the distal RCA. Thrombotic occlusionat this site was simply caused by the stagnation of blood flowfollowing the upper site occlusion. While pathophysiological datawere lacking in this case, OCT and IVUS images helped us to identifythe different mechanisms of the thrombotic occlusions in the samecoronary artery.

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ijcard.2014.01.014.

The authors of this manuscript have certified that they complywith the Principles of Ethical Publishing in the International Journalof Cardiology.

References

[1] Cho JM, Raffel OC, Stone JR, Kim CJ, Jang IK. Spontaneous recanalization of acoronary artery after thrombotic occlusion: in vivo demonstration with opticalcoherence tomography. J Am Coll Cardiol 2010;55:1274.

[2] Kato K, Dote K, Sasaki S. Recanalized image of thrombotic occlusionwith coronaryplaque rupture: a lotus root-like appearance by optical coherence tomography.Can J Cardiol 2011;27(871):e1–2.

Fig. 1. A: Coronary angiography independently showed severe stenosis with braid-like appearance at the middle and the distal segments of the right coronary artery (RCA).B:Enlarged image showing in-stent restenosis with braid-like appearance at the distal segment of RCA.

⁎ Corresponding author at: Department of Cardiology, Aichi Medical University, 1-1Yazakokarimata, Nagakute, Aichi, 480-1195, Japan. Tel.: +81561 62 3311; fax: +8156163 8482.

E-mail address: h0914@aichi-med-u.ac.jp (H. Takashima).

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0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijcard.2014.01.014

Glutamate neurotoxicity is involved in the neurological damage in patientsundergoing extracorporeal circulation

Francisco Campos a,1, Tomás Sobrino a,1, Miguel Blanco a, Esteban López-Arias a, Aurora Baluja b,Julián Álvarez b, José Castillo a,⁎a Department of Neurology, Neurovascular Area, Clinical Neurosciences Research Laboratory, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS),University of Santiago de Compostela, Santiago de Compostela, Spainb Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Health Research Institute ofSantiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain

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Article history:Received 30 December 2013Accepted 6 January 2014Available online 15 January 2014

Keywords:GlutamateExtracorporeal circulationNeurological damageGlutamate scavengers

Homeostasis of brain glutamate is a process that is highly energydependent. Therefore, restriction of blood supply leads to a rapidbuildup of excess glutamate in the brain parenchyma followed byneuronal death [1]. Ischemic stroke represents one of the bestexamples of restriction of cerebral blood flow in the brain. However

Fig. 2. Optical coherence tomography and intravascular ultrasound findings.A: Usual atherosclerotic change without lotus root-like appearance at the proximal segment.B: Severestenosis with superficial calcification at the proximal segment.C: Vascular enlargement without a part of media at the middle segment.D: Lotus root-like appearance at the middlesegment.E: Usual atherosclerotic change without lotus root-like appearance at the proximal site of bare metal stents.F: Lotus root-like image appearance in bare metal stents at thedistal segment.G: Distal part of bare metal stents showing lotus root-like appearance at the distal segment.*Showed lotus root-like appearance.

⁎ Corresponding author at: Servicio de Neurología, Hospital Clínico Universitario, c/Travesa da Choupana s/n, 15706 Santiago de Compostela, Spain. Tel.: +34 981951348;fax: +34 981951098.

E-mail address: jose.castillo@usc.es (J. Castillo).1 These authors contributed equally to this work.

it is also well described that surgical interventions such as carotidangioplasty or stent placement (CAS) procedures cause a briefperiod of cerebral blood flow interruption which results in a rapidincrease of glutamate levels [2]. These results reveal that shortperiods of ischemia are able to alter the brain glutamate home-ostasis, even in patients without evidence of neuronal tissue damageanalyzed by magnet ic resonance imaging (MRI) [2] .Extracorporeal circulation (ECC) is another type of surgical inter-vention that involves some risks such as brain transient ischemia.However, to date, there are not yet clear clinical data regarding themolecular mechanism involved in this process. Therefore, the aim ofthis study was to analyze the role of glutamate in the neurologicaldamage of adult patients subjected to ECC.

In this prospective study, we included 78 patients (66.7% males,mean age 61.9 ± 13.8 years) who underwent ECC. From the sampleincluded, indications for ECC were the following: coronary surgery (28patients), heart valve surgery (21 patients), aortic surgery (25 patients),and 4 patients for other causes. This research was carried out inaccordance with the Declaration of Helsinki of the World MedicalAssociation (2008) andapprovedby theEthics Committeeof the ServizoGalego de Saúde. Informed consent was obtained from each patient ortheir relatives after full explanation of the procedures.

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