Abstract
A 54-year-old man, current smoker, without previous cardiovascular history was admitted for an inferior transient ST-segment elevation myocardial infarction. An emergent coronary angiogram revealed an unstable, non-obstructive, thrombus-rich plaque in the mid segment of the right coronary artery (RCA) (Panel A). Optical coherence tomography (OCT) imaging disclosed a healthy vessel wall in the proximal RCA, along with a long, heterogenous plaque at the culprit lesion, where three distinct phenotypes were clearly recognized (Panels a-d, circle denotes wire artifact). First, the very proximal segment of the plaque showed a layered morphology with multiple high and low signal-rich strata, suggestive of an old healing process (Panels a and b, arrowheads). In the middle part of the plaque, a superficial, laden, organized circumferential thrombus was observed, probably reflecting an early healing stage (Panel c, asterisks). Finally, the most distal part of the lesion showed a plaque rupture with a large, ‘red’ fibrin-rich, fresh protruding thrombus (Panel d, star). Percutaneous coronary intervention with a new-generation stent obtained excellent results.
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