Article ID: CJ-22-0619
A 57-year-old man with a history of coronary artery bypass graft surgery and hemodialysis-dependent chronic renal failure was found to have severely calcified coronary arteries including the entire aorta on computed tomography (CT) angiography (Figure A–D). A percutaneous coronary intervention (PCI) was performed on a stenotic lesion with evident ischemia in the left circumflex artery unprotected by bypass grafts. Non-obstructive general angioscopic (NOGA) observation of the aorta subsequent to the PCI was performed to screen for atherosclerosis. Spontaneously ruptured atheromatous plaques, called puff-chandelier ruptures, were detected in the whole aorta (Figure E–G). Histological analysis revealed atheromatous material including several cholesterol crystals (CCs) (Figure H–K) in the sampled blood from the puff-chandelier rupture site (Figure E). Although previous studies have shown the benefit of statin use to decrease cardiovascular disease (CVD) in the general population, lipid-lowering therapy is controversial for dialysis patients.1 One of the reasons has been that mainly calcified plaques rather than atheromatous plaques of vascular lesions in dialysis patients have previously been reported. In this case, however, NOGA detected many aortic vulnerable plaques obscured by calcifications on CT. Aortic plaques detected by NOGA could be an independent risk factor for CVD.2 CCs from disrupted plaques lead to inflammatory organ injury.2 NOGA may help identify vulnerable plaques obscured by calcifications on CT and elucidate the plaque morphology in dialysis patients.
(A) Maximum intensity projection of 3D-computed tomography (CT) angiography performed 6 months prior shows diffuse calcification of the whole aorta. Severe calcification of (B) the transition zone of the ascending aorta to the lesser curvature of the aortic arch, (C) descending aorta at the 11th-level lumbar vertebra, and (D) abdominal aorta at the 2nd-level lumbar vertebra on enhanced CT. (E) Angioscopy shows puff-chandelier rupture, which are severe atheromatous plaque lesions on the level corresponding to (B). (F) A puff-chandelier rupture with a deep ulcer on the level corresponding to (C). (G) Puff-chandelier rupture of an intense plaque lesion at the level corresponding to (D). Debris of the sampled puff-chandelier rupture corresponding to (E) in (H) low and (I) high magnification (H&E). (I) Arrows indicate spaces considered to be cholesterol crystals. (J) Cholesterol crystals. (K) Cholesterol crystals under polarization microscopy.
We thank Mr. John Martin for proofreading the manuscript.
None.
