Intraluminal Filling Defects on Coronary Angiography: More than Meets the Eye

Ronen Jaffe, Affan Irfan, Tony Hong, Robert J. Chisholm, Asim N. Cheema
2007 Clinical Cardiology  
Intraluminal filling defects are occasionally encountered on coronary angiography and often related with coronary thrombi. However, other conditions affecting the coronary arteries may present with similar angiographic findings causing diagnostic uncertainty. Accurate characterization of the angiographic filling defect is critical, particularly in patients planned for a percutaneous coronary intervention (PCI), as diagnosis of a coronary thrombus not only increases the risk of post procedural
more » ... f post procedural adverse events but also requires a specific therapeutic approach. In this paper, we report three patients in whom coronary angiography revealed intraluminal filling defects mimicking coronary thrombi. When further investigated with intravascular ultrasound (IVUS) as a part of the planned PCI, the thrombus was excluded and alternate etiology of the filling defect was confirmed in all patients. The angiographic "pseudothrombi" were produced by coronary dissection in one and by heavy calcification within the atherosclerotic plaque in two patients. The use of IVUS allowed accurate characterization of the angiographic filling defect and provided important information to guide management and optimize therapeutic approach. Coronary angiography is a common investigation performed in patients suspected with coronary artery disease. 1 Intraluminal filling defects are occasional findings on coronary angiography and may present a diagnostic and a therapeutic dilemma. Although they are often associated with intra coronary thrombi, particularly in the setting of an acute coronary syndrome, several other pathologies such as coronary artery dissection, emboli, mural calcification and unopposed stent struts in a previously stented segment may also result in similar angiographic findings. As the treatment markedly differs for these diverse conditions, it is imperative to characterize the true nature of these filling defects for proper diagnosis and management. In this paper, we report three cases with intraluminal filling defects that mimicked thrombi on coronary angiography. However, further interrogation with IVUS revealed alternate causes for the angiographic appearance. The accurate identification of the underlying pathology allowed application of a specific treatment strategy with good clinical outcome. Case 1 An 85-year-old man with past medical history of hypertension, dyslipidemia and peripheral vascular disease was hospitalized after an inferior ST-elevation myocardial infarction. He did not receive thrombolytic therapy due to late presentation, but experienced further angina after admission to the coronary care unit. Coronary angiography revealed moderate disease in the left coronary artery and two intraluminal filling defects in the mid-segment of the right coronary artery (RCA), Fig. 1(A) , suggesting presence of thrombi. An IVUS
doi:10.1002/clc.20062 pmid:17803206 fatcat:rlrxcpmsk5hajjhanqown2q3di