- Case report
- Open Access
- Open Peer Review
A honeycomb-like structure in the left anterior descending coronary artery treated using a scoring device and drug-eluting stent implantation: a case report
© Haraki et al. 2016
- Received: 14 February 2016
- Accepted: 17 March 2016
- Published: 1 April 2016
A honeycomb-like structure in the coronary artery is rarely diagnosed by intracoronary ultrasound or optical coherence tomography. Further, its structural mechanisms and response to interventional therapy remain unknown.
A 59-year-old Japanese man was referred to our hospital because of acute decompensated heart failure with rapid atrial fibrillation. After receiving anticoagulant therapy, a coronary angiogram revealed a braid-like appearance and an intracoronary ultrasound image confirmed a honeycomb-like structure in the mid left anterior descending coronary artery. We inserted two guide wires into different partitions. Although a balloon angioplasty with a scoring device could not completely fenestrate these partitions, a stent implant was able to completely compress the structure easily.
The honeycomb-like structure of the left anterior descending coronary artery in our patient was suspected to be because of recanalization of a cardiogenic embolism. This structure may have been composed of relatively hard tissues, but was easily compressed by a stent implantation.
- Honeycomb-like structure
- Coronary artery
- Scoring devices
- Stent implantation
There are several case reports of a honeycomb-like structure (or lotus root-like appearance) observed in the coronary artery of patients with Kawasaki disease, antiphospholipid syndrome, embolic stroke, atrial fibrillation, and acute coronary syndrome [1–7]. However, its structural mechanisms and response to interventional therapy remain unknown. We report the case of a patient with a honeycomb-like structure in the mid left anterior descending coronary artery (LAD), which was treated by intervention using a scoring device and implantation of a drug-eluting stent.
Initially, we intravenously administered diuretics, carperitide (0.033 μg/mL/minute), digitalis, and heparin (12000 U/d). By the following day, the atrial fibrillation had converted to an atrial flutter (2:1 to 4:1 conduction); however, the electrocardiogram showed no ST-T change except for poor R wave progression in leads V1–V4. In addition, troponin T (0.045 ng/mL) and CK-MB (6 U/L) levels were not elevated on the following day. We considered that there were no complications arising from acute coronary syndrome, and therefore, we continued the conservative treatment. Our patient required additional medication, including diltiazem and bisoprolol, to control the rate of the atrial flutter.
After 14 days of admission (prior to discharge), a repeat echocardiogram confirmed the persistence of global left ventricular hypokinesis with an LVEF of 19 %. We managed this condition by administering aspirin, 100 mg; clopidogrel, 75 mg; apixaban, 5 mg; furosemide, 40 mg; spironolactone, 25 mg; digoxin, 0.125 mg; metoprolol, 2.5 mg; and perindopril, 4 mg.
The sinus rhythm was maintained for 11 months following stent implantation, and there were no events relating to ischemic or decompensated heart failure during this time. After 11 months, another echocardiogram showed moderate hypokinesis in anteroseptal and inferior walls, a left ventricular end-diastolic dimension of 57 mm, and it confirmed that LVEF had improved to 44 %. After 14 months, a repeat CAG confirmed that there had been no recurrence of stenosis at the stent implantation site in the mid-LAD, and no other stenotic lesions were evident (Figs. 3i, j).
Several case reports have indicated that the honeycomb-like structure (or lotus root-like appearance) observed in the coronary artery by IVUS or optical coherence tomography (OCT) is caused by a spontaneous recanalization of thrombi (for example, an organized thrombus) [3–5]. An organized thrombus includes new capillary vessels and hyperplasia of the elastic and collagen fibers, which results in thrombi. OCT revealed that the septa in the honeycomb-like structure was composed of a high signal intensity and a low signal attenuation, suggesting that it consisted of a fibrous material that represented the recanalization of a cardiogenic embolism. In our patient, this structure was mixed with high and low echoic partitions by IVUS. It was suspected that the degree of fibrosis may be related to the echogenicity . This structure could not be completely fenestrated by a balloon angioplasty with a scoring device, even with the buddy wire technique. However, stent implantation did completely compress this structure, indicating that it was likely composed of relatively hard tissues, which may have included fibrous material. Although we did not evaluate this structure histologically, from a clinical perspective, this honeycomb-like structure of the LAD is thought to be due to cardiogenic thrombus recanalization rather than plaque erosion. It is reported that the resolution of left atrial appendage thrombus was observed with apixaban, a member of the class of novel oral anticoagulants (NOAC) . We performed IVUS after 9 days of apixaban treatment. Apixaban usage may have modified the tissue characteristics of this honeycomb-like structure.
Furthermore, it has been reported that a lesion with a lotus root-like appearance in stable coronary artery disease was functionally severe stenosis, identified by myocardial fractional flow reserve and coronary flow velocity reserve indexes . In our patient, the sinus rhythm was maintained for 11 months after stent implantation, and a repeat CAG confirmed that there had been no recurrence of stenosis at the stent implantation site in the mid-LAD, however, the LVEF was not fully improved (44 % by echocardiograph). Further careful follow-up is needed to check his cardiac function as well as to avoid the recurrence of atrial fibrillation and/or embolic events.
We present the case of patient with a honeycomb-like structure in the LAD that was suspected to be because of recanalization of a cardiogenic embolism. This structure may have been composed of relatively hard tissues, but was easily compressed by stent implantation.
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-in-Chief of this journal.
We wish to thank our staff at the catheterization laboratory and the nursing staff who participated in the treatment of this patient.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Terashima M, Awano K, Honda Y, Yoshino N, Mori T, Fujita H, et al. “Arteries within the artery” after Kawasaki disease: a lotus root appearance by intravascular ultrasound. Circulation. 2002;106:887.View ArticlePubMedGoogle Scholar
- Nakanishi T, Kawata M, Matuura T, Kuroda M, Mori K, Hirayama Y, et al. A case of coronary lesion with lotus root appearance treated by percutaneous coronary intervention with intravascular ultrasound guidance. Cardiovasc Interv Ther. 2010;25:131–4.View ArticlePubMedGoogle Scholar
- Cho JM, Raffel OC, Stone JR, Kim CJ, Jang IK. Spontaneous recanalization of a coronary artery after thrombotic occlusion: in vivo demonstration with optical coherence tomography. J Am Coll Cardiol. 2010;55:1274.View ArticlePubMedGoogle Scholar
- Toutouzas K, Karanasos A, Stathogiannis K, Synetos A, Tsiamis E, Papadopoulos D, et al. A honeycomb-like structure in the left anterior descending coronary artery: demonstration of recanalized thrombus by optical coherence tomography. JACC Cardiovasc Interv. 2012;5:688–9.View ArticlePubMedGoogle Scholar
- Musashi M, Tada N, Uemura N, Kawashima O, Ootomo T, Inoue N, et al. Multivessel honeycomb-like structure finding in optical coherence tomography. JACC Cardiovasc Interv. 2014;7:e7–8.View ArticlePubMedGoogle Scholar
- Koyama K, Yoneyama K, Mitarai T, Kuwata S, Ishibashi Y, Kongoji K, et al. In-stent protrusion after implantation of a drug-eluting stent in a honeycomb-like coronary artery structure: complete resolution over 6 months and the role of optical coherence tomography imaging in the diagnosis and follow-up. JACC Cardiovasc Interv. 2014;7:e39–40.View ArticlePubMedGoogle Scholar
- Kimura T, Itoh T, Fusazaki T, Nakamura M, Morino Y. A honeycomb-like structure in the right coronary artery visualized by three-dimensional optical coherence tomography. Coron Artery Dis. 2015;26:356–60.View ArticlePubMedGoogle Scholar
- Kawakami T, Kobayakawa H, Ohno H, Tanaka N, Ishihara H. Resolution of left atrial appendage thrombus with apixaban. Thromb J. 2013;11:26.View ArticlePubMedPubMed CentralGoogle Scholar
- Suzuki M, Seki A, Nishikawa K, Takamizawa I, Tobaru T, Sumiyoshi T. Novel physiological insight into a lotus root appearance in stable coronary artery disease; report of two cases. Cardiovasc Interv Ther. 2015.Google Scholar