Integration of computed tomography and intravascular ultrasound for optimal management of chronic total occlusions with intramyocardial bridge: a case report

Summary

Chronic total occlusions (CTOs) are a challenging scenario in coronary artery disease. Coronary computed tomography (CT) has becoming increasingly valuable in CTO-percutaneous coronary intervention (PCI), by also allowing pre-procedural identification of intramyocardial bridges (IMBs), which impact long-term outcomes in CTOs.¹

Case description

An 80-year-old male with refractory angina (CCS III) despite optimal medical therapy and prior coronary artery bypass grafting presented with an occluded graft and a mid-left descending artery (LAD) CTO (Figure 1A; Supplementary material online, Video S1), with extensive collateral circulation and stress echocardiogram showing anterior wall viability. Pre-procedural CT revealed an IMB compressing the distal CTO segment, complicating its management (Figure 1B). Computed tomography detects IMBs by identifying systolic luminal narrowing (milking-effect), helping assess their haemodynamic significance. Computed tomography findings allowed a pre-procedural planning of a conservative approach for the IMB-affected segment. The lesion was crossed by a high-penetration guidewire (Gaia 1™, Asahi-Intecc, Japan), and non-compliant balloon pre-dilation restored the flow (Figure 1C). Intravascular ultrasound (IVUS), according to plaque-burden and minimal-lumen-area, accurately identified an optimal stent-landing zone, also sparing the IMB-affected segment (detected with its typical half-moon sign, Figure 1D), which was treated with a drug-eluting-balloon (DEB, Figure 1E). This strategy avoided potential IMB-related complications such as in-stent restenosis or fracture.² The procedure achieved excellent results (Figure 1F and G), with IVUS confirming IMB-sparing from stenting (Figure 1H), and with no residual angina reported (along with beta-blocker treatment).

Figure 1

(A) Baseline angiography showing the occluded LAD segment; (B) CT evidence of intramyocardial bridge within the CTO lesion; (C) coronary flow restore after balloon; (D) IVUS of the CTO area showing the boundary between IMB (with the typical ‘half-moon’ sign) and IMB-free area; (E) boundary between DES-treated area (without IMB) and DEB-treated area (within IMB course); (F and G) final result; (H) IVUS confirming IMB-area spared from stent implantation.

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Computed tomography and IVUS integration allowed precise planning and optimization of CTO-PCI, highlighting the role of coronary imaging in managing complex CTO cases involving IMBs. Conservatively sparing IMB-affected segments with DEB prevented stent-related complications, as mechanical stress caused by IMBs can lead to stent failure.³ Since long-term data are still limited, this case shows this approach’s feasibility and safety, thanks to coronary imaging support.

Integrated precision-medicine approaches with coronary CT and IVUS are crucial in identifying IMBs and guiding CTO-PCI management, minimizing harmful stenting and improving outcomes.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Consent: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.

Funding: None declared.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

References

Author notes