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Instructive percutaneous coronary intervention to avoid the risk of side branch occlusion at a lesion with a lotus root appearance: a case report
© The Author(s). 2016
Received: 25 March 2016
Accepted: 27 July 2016
Published: 2 August 2016
A lotus root appearance is a rare entity, and there is little opportunity to perform coronary intervention for this kind of lesion. Because of its peculiar anatomical characteristics, one of the problems regarding percutaneous coronary intervention (PCI) for these lesions is related to the involvement of branch vessels.
We encountered a case of PCI for a stenotic lesion with a lotus root appearance in the mid-portion of the right coronary artery (RCA). To avoid the risk of right ventricular (RV) branch occlusion due to stent deployment in the main RCA, we re-crossed the third guidewire into the main RCA via the nearest point to the RV branch ostium through the communicating vascular lumen. Thereafter, we deployed a drug-eluting stent in the main RCA crossing over the RV branch, and the ostium of the RV branch remained intact, as we expected.
This case is the first report in the world describing the details of how to maintain the patency of the side branch bifurcating from a lesion with a lotus root appearance under optical coherence tomography guidance.
A lotus root appearance is a rare entity that can be detected by intravenous ultrasound sonography (IVUS) or optical coherence tomography (OCT) during the daily practice of coronary catheterization. Lesions with a lotus root appearance are characterized by multiple vascular channels separated by wall partitions, communicating with each other and converging into a single lumen at proximal and distal sites. The detailed origin of the lotus root appearance is still unknown. Although there is little opportunity to perform coronary intervention for this kind of lesion, we always have to be aware of how to maintain the patency of a side branch (SB) bifurcating from a lesion with a lotus root appearance.
His chest symptom fully resolved after this intervention and no adverse events have been observed since then. We performed follow-up coronary angiography (CAG) at 8-month after PCI. Favorable blood flow was observed in both the main RCA and the RV branch, and OCT findings showed better strut apposition and coverage with neointimal formation.
We encountered a patient who required coronary intervention for the mid-portion of the RCA with a lotus root appearance detected during a survey with OCT. A lotus root appearance was firstly reported as a lesion composed of multiple channels observed by IVUS in a young patient who had a history of suspected Kawasaki disease in 2002 . Although the detailed origin of the lotus root appearance is still unknown, “arteries within the artery” was first described as spontaneous recanalization after coronary thrombotic events in a patient with Kawasaki disease , and it is believed to be identical to a lotus root appearance.
A lesion with a lotus root appearance is characterized by multiple vascular channels separated by wall partitions, communicating with each other and converging into a single lumen at proximal and distal sites. As the OCT has become widely used, more and more cases with this kind of lesion have been reported not only in coronary arteries [3, 4] but also in carotid arteries . However, not so many cases have received PCI for this kind of lesion. Several cases verified the validity of performing PCI for these lesions based on a significant decrease of the fractional flow reserve value [6, 7]. Functionally significant ischemic findings are often demonstrated at a lesion with a lotus root appearance, whereas the stenosis rate at that lesion angiographically shows a moderate degree. The reason for the “visual -functional mismatch” is suggested from the OCT images in which the dead end of the majority of multiple intraluminal channels except a skinny channel can cause markedly limited coronary flow.
It is considered that one of the problems regarding PCI for these lesions is related to the involvement of the branch vessels. A previous case report described a strategy to prevent occlusion of the SB which bifurcated from a lesion with a lotus root appearance . In this case report, the operator confirmed the route through which the guidewire passed from the main vessel (MV) to the SB using IVUS. However, the authors did not describe the details about the methods to cross the guidewire into the SB through the optimal branch ostium at the lesion with the lotus root appearance. Similarly in our case, we were concerned about the risk of SB occlusion after stenting in the MV. To avoid this problem, we considered it important to deposit the guidewire using the optimal route. From the findings of OCT, the point at that the vascular lumen most distally branching from the MV was thought to be the true bifurcation point. The Sion blue guidewire branched off toward the RV branch from a point more proximal than the true bifurcation point, and some partition walls existed between the two guidewires (Fig. 2f). Therefore, to avoid SB occlusion due to deploying a stent in the MV, we had to re-cross the guidewire using the optimal route in the main RCA via the nearest point to the RV branch ostium.
We performed all PCI procedures with the guidance of OCT. The high resolution of OCT remarkably helped us to clearly detect the guidewire position in the lesion with a lotus root appearance. Moreover, OCT is also very useful for characterization of stent healing and vascular responses in the chronic phase as well as accurate procedures in PCI. As shown in recent systemic review, we confirmed better strut apposition and coverage with neointimal formation after zotarolimus-eluting stent implantation in the follow-up CAG .
In this case, we took advantage of the Crusade dual lumen microcatheter when introducing the third guidewire along the optimal route. The dual lumen microcatheter allows the operator to deliver the second guidewire through the over-the-wire lumen into the same vascular lumen where the first guidewire exists. Because the vascular lumens are intricately connected with each other around the lesion with a lotus root appearance, we think the dual lumen microcatheter is optimal for this kind of lesion. The dual lumen microcatheter is a very useful device for multipurpose use in practical PCI. It can help us to perform complex PCI procedures more safely, speedily, and steadily.
A lotus root appearance is a rare entity detected by IVUS or OCT during the daily practice of coronary catheterization. Although there is little opportunity to perform coronary intervention for a lesion with a lotus root appearance, we always have to pay attention to how to maintain the patency of the SB bifurcating from a lesion with a lotus root appearance.
CAG, coronary angiography; IVUS, intravenous ultrasound sonography; MV, main vessel; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; RCA, right coronary artery; RV, right ventricular; SB, side branch
Availability of data and material
All the data supporting our findings is contained within the manuscript.
TN is the primary author of this paper. TK, HK, DM, RU, TS, YH, NK and TT made substantial editorial revisions to the manuscript. TK made major contributions to the conception and design. All authors read and approved the final manuscript.
The authors declare that they have no conflicting interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Ethics approval and consent to participate
The study was performed in accordance with the Declaration of Helsinki and approved by the institutional ethical board of Nantan General Hospital.
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