ANGIOSCOPIC FINDINGS DURING CORONARY ANGIOPLASTY OF CORONARY OCCLUSIONS

Objectives. This study sought to elucidate angioscopic findings in tot ally occluded vessels before and after intervention. Background. Coron ary angioscopy allows direct visualization of the lumen surface of the coronary arteries; however, the utility of coronary angioscopy during coronary angioplasty of vessels with a total occlusion is unknown. Me thods. Twenty-one consecutive patients (mean [+/-SD] 58 +/- 9 years, r ange 39 to 77; 3 women, 18 men) undergoing dilation of an occluded ves sel were studied with coronary angioscopy. Occlusions were classified as functional in 8 patients (Thombolysis in Myocardial Infarction [TIM I] how grade 1) and anatomic in 13 (TIMI flow grade 0). Once the guide wire had crossed the occlusion, coronary angioscopy was attempted bef ore and after angioplasty. Results. In all patients, coronary angiosco py before dilation visualized protruding material occluding the corona ry lumen where the guide wire was wedged. The occlusion consisted of r ed thrombus in 19 patients (90%) (2 with isolated occlusive thrombus, 17 with thrombus associated with atherosclerotic plaque) and protrudin g yellow plaque in 2 patients (10%). However, on angiography only 7 oc clusions (33%) had data consistent with thrombus (p < 0.01 vs. coronar y angioscopy). Successful dilation was obtained in 20 patients. After dilation, coronary angioscopy was repeated in 18 patients, revealing r esidual thrombus with plague in 16 (89%) and a residual yellow plaque in 2. In addition, coronary angioscopy revealed coronary dissections i n 13 patients (72%); however, angiography revealed dissections only in 10 patients (55%) and residual thrombus in 2 (10%) (p < 0.001). In on e patient, coronary angioscopy visualized silent distal embolization o f a red thrombus not previously recognized on angiography. Conclusions . Before intervention, coronary angioscopy provides unique insights in to the pathologic substrate of occluded coronary vessels. An occlusive plaque with thrombus is the most common underlying substrate in these lesions. After successful dilation, angiographically silent mural thr ombus is seen in most patients. This information could be used to assi st in the selection of candidates and type of coronary interventions a nd could also prove to be of prognostic value in patients with occlude d