Case Report
Woven Coronary Artery with acquired etiology: the natural history documented by serial angiography and optical coherence tomography
https://doi.org/10.21203/rs.3.rs-4335586/v1
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Woven coronary artery (WCA) is a rare anomaly and its etiology remains speculative. Both congenital and acquired factors are considered to be concerned with the pathogenesis. In a 35-year-old man, the tissue characteristics of WCA were evaluated by optical coherence tomography. Serial coronary angiography indicated that acquired factor is the cause, and thrombus recanalization is the most likely pathological mechanism.
Woven coronary artery
Optical coherence tomography
Coronary angiography
Woven coronary artery (WCA) is a rare anomaly and the exact etiology is still unknown[1]. It is angiographically characterized by that the epicardial coronary artery is divided into multiple thin channels at the proximal segment and converged together in the distal segment, with a TIMI III distal blood flow[2]. Since the first case report, fewer than 40 cases of WCA have been reported[1, 3]. Both congenital and acquired origins were considered for WCA. However, the etiology is speculative as lack of longitudinal natural history data. Herein, we report a case with WCA in the left anterior descending artery (LAD) at age 35, but coronary angiography (CAG) showed only mild stenosis at age 28. Optical coherence tomography (OCT) imaging was performed to characterize the features of the lesion.
A man at age 28 was admitted to our hospital for chest pain for 1 day in September 2016. He had a history of hypertension, dyslipidemia and surgical atrial septal defect closure. CAG showed less than 50% stenosis in proximal segment of LAD (Fig. 1A). The patient was treated with aspirin, nitrate, β-blocker and statin after discharge. He was readmitted to our hospital for paroxysmal chest pain for 1 month at age 35 in April 2023. His vital signs were normal, and no obvious abnormality was found in laboratory examination, electrocardiogram, chest X-ray and cardiac ultrasound.
CAG revealed severe stenosis in the proximal and middle LAD and twisting channels was seen in the diseased segments (Fig. 1B). With the aid of a microcatheter, a Fielder XT-A guidewire was crossed the lesion and exchanged to a workhouse guidewire. After low pressure dilation with a 2.0 mm balloon (6 atm) and OCT examination, a 3.0 × 36 mm stent was implanted in proximal and middle segment of LAD (Fig. 1C). OCT imaging were performed before stent implantation and demonstrated multiple lumens separated by fibrous tissue and the lumens shared the media and adventitia (Fig. 1D and E). There were two separated main channels in the diseased segments. The guidewire and the OCT catheter were located in the larger channel and no communication were found with the smaller one. The later originated from the proximal segment (Fig. 1D ①, ②), soon emitted multi-microchannels (Fig. 1D ③ to ⑦) and then converged (Fig. 1D ⑧). Again, it emitted multi-microchannels (Fig. 1D ⑨ to ⑭) and then converged (Fig. 1D ⑮ to ⑱). Both CAG and OCT indicated features of a WCA in the proximal and middle LAD. As CAG showed only mild stenosis in proximal LAD 7 years ago, we consider that the woven change of LAD was acquired and caused by the recanalization of thrombus. During one year follow-up, the patient had no adverse cardiovascular events or discomforts. This study was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Fuwai Hospital. The patient provided written informed consent.
Here we show a natural history of WCA in LAD of a young man by serial CAG in a 7-year interval, and the lesion features were visualized by OCT imaging. Our case indicates an acquired cause of WCA and most likely resulted from recanalized thrombus. This supports the finding in another report, in which WCA development was observed in the right coronary artery by serial CAG in a 6-year interval, and the lesion characteristics were observed by intravascular ultrasound (IVUS) [4]. Till now, only these two case reports described the natural history of WCA by serial CAG.
One pathological mechanism proposed for WCA is congenital[5]. However, there is lack of data showing that WCA has a genetic predisposition or hereditary characteristic. The OCT image features of WCA is summarized as follows: (1) Intertwined thin channels separated by fibrous tissue without cross-communications among them; (2) Undisrupted arterial wall integrity without dissection; and (3) High signal intensity and low signal attenuation[1]. Although it is not conclusive, no cross-communications is proposed as a key feature in distinguishing congenital WCA from other etiologies, such as thrombus recanalization[1]. In the current case which is acquired, we also found no cross-communications among the lager and the smaller channels by OCT. However, the smaller channel itself has multiple microchannels and cross-communications exist among them. Taking into account the limited number of published case reports, we consider that no cross-communications among the channels is just one type of WCA, thus could not be used as a criterion for differential diagnosis.
The other proposed pathological mechanism for WCA is acquired factors, including thrombus recanalization, spontaneous coronary artery dissection (SCAD) or bridging collaterals of chronic total coronary occlusions (CTO). It is not rare that neovascular channels form in the CTO segments, but histologic studies show their diameters range from 160 to 230 µm[6]. As the diameters of two main channels (2000 µm and 1000 µm, respectively) in the current case were much larger than that of neovascular channels in CTO lesions, they are unlikely resulted from recanalization of a CTO. In addition, SCAD is known as a nonatherosclerotic disease and women comprise 87–95% of the patients[7]. Thus, we may exclude the etiology of healed SCAD as CAG indicated an atherosclerotic lesion in the same location 7 years ago. Consequently, recanalization of thrombosis is most likely to be the underline mechanism for this case. Taken together with the previously reported case[4], which also observed a natural history of WCA, we speculate that WCA is most likely an acquired coronary artery disease.
In the past, WCA was deemed to be a benign abnormality and usually do not need intervention[8]. It is now recognized that WCA may lead to ischemia and even myocardial infarction and surgical or percutaneous revascularization is indicated in such patients [1]. The literature review of case reports (37 cases) showed that 24 (50.4%) cases were single vessel disease, and 18 (48.6%) cases underwent revascularization. Among them, 5 (13.5%) cases received coronary artery bypass graft (CABG) and 13 (35.1%) cases underwent percutaneous coronary intervention (PCI)[1]. Thus, PCI is a therapeutic option for most of WCA patients with documented ischemia when the anatomy is suitable. We suggest two technical points when PCI is planned for WCA: (1) Use polymer sleeve CTO guidewires to cross the lesion with sliding and rotating technique. If it does not work, penetration technique with coiled CTO guidewires may be considered; and (2) Confirm that the multi-channels share the media and the guidewire locates inside the media by intravascular imaging, so that the stent could be safely expended without risk of perforation.
This case provided strong evidence that acquired etiology is the most likely pathological mechanism for WCA.
WCA, woven coronary artery; CAG, coronary angiography; LAD, left descending artery
The authors have nothing to disclose.
It is from the ethics committee of the department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, China.
Consent for publication:
Written informed consent for publication was obtained from all participants.
This study was supported by the CAMS Innovation Fund for Medical Sciences (number: 2023-I2M-C&T-B-069).
Conception and design of the work: Hanjun Zhao; acquisition, analysis and interpretation of data: Jiannan Li and Xiaoli Wang; drafted the work and substantively revision: Chen Liu and Peng Zhou
The datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.
No competing interests reported.
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