Coronary Caverns: Spontaneous Recanalized Chronic Total Occlusion With Multiple Microchannels

Key words: angiography, chronic total occlusion

A 65-year-old man with a prior history of pulmonary embolism was admitted with resting chest pain. High-sensitive troponin level was normal (32 ng/L [0-40]) and physical examination was unremarkable. The 12-lead electrocardiogram revealed sinus bradycardia (42 bpm) with T-wave inversion in the inferolateral leads (II, III, AVF, I and AVL). Transthoracic echocardiography demonstrated hypokinesia of the basal to mid inferior and inferolateral walls with a mildly impaired left ventricle systolic function (ejection fraction 45%-50%). Following dual-antiplatelet therapy (DAPT) for high-risk acute coronary syndrome, he underwent an urgent coronary angiogram, which revealed unobstructed left main stem, left anterior descending, and left circumflex arteries, and a large dominant right coronary artery (RCA) with diffuse irregularity through its mid segment. A Thrombolysis in Myocardial Infarction (TIMI) class 3 flow was observed; however, due to this unusual appearance of the RCA, further evaluation with optical coherence tomography was undertaken. This confirmed a recanalized chronic total occlusion (CTO) with multiple microchannels (Figure 1). As there was TIMI 3 flow, no coronary intervention was required and he was discharged with optimal medical therapy, including DAPT. He remained well at 1-year follow-up.

Spontaneous CTO recanalization is rare. It has scarcely been described previously and with minimal visual detail. Optical coherence tomography permitted comprehensive visualization of the microchannels in our case, seldom seen previously. With TIMI 3 flow in the affected vessel via these patent channels, optimal medical therapy may be an appropriate strategy.

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Affiliations and Disclosures

From the Cardiology, Ashford and St Peter’s Hospitals NHS trust, Surrey, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sharma reports speaker income and educational grants from Bayer, Abbott Medical, Bristol-Myers Squibb, Boston Scientific, and Pfizer. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted January 3, 2022.

Address for correspondence: Zaki Akhtar, MBBS, Ashford and St Peter’s Hospital NHS trust, Guildford Road, Chertsey, Surrey, United Kingdom, KT16 0PZ. Email: Zakiakhtar@nhs.net