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Thrombus overlying the main stem crista: a three dimensional reconstruction

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A 67 year old patient was referred to our hospital for diagnostic catheterisation. For six days she had been suffering from unstable angina, which was stabilised medically. She had no coronary risk factors. The diagnostic angiogram showed a large thrombus reaching from the first diagonal branch through the proximal left anterior descending artery (LAD), overlying the main stem crista and reaching distally of the first marginal branch into the left circumflex artery (LCX). Intravascular ultrasound (IVUS) of the LAD showed a smooth, organised thrombus crossing the first diagonal and septal branch of the LAD without presence of atherosclerotic disease of the artery. The three dimensional reconstruction shows the thrombus alongside a  normal arterial wall. The patient was treated with abciximab bolus and 24 hour infusion. She remained free of symptoms and was again catheterised four days later. Angiography and IVUS showed complete dissolution of the thrombus, and the patient was discharged from the hospital. As the control angiogram and IVUS images revealed no significant coronary artery disease, we hypothesised a left cardiac or paradoxical (in the case of an atrial or ventricular septal defect or a patent foramen) origin of the thrombus. Transthoracic and oesophageal echocardiograms, however, revealed no thromboembolic origin. Possibly, rupture of a minimal plaque marked the onset of the acute coronary syndrome. On aspirin treatment, she remains free of cardiac complaints four months after the initial event.

Coronary angiogram (RAO view) of LAD (top) and CX (bottom) in the lower left corner, showing thrombus (t) overlying the main stem crista. The lower right picture shows the LAO view. The lower centre shows an IVUS longitudinal reconstruction of the LAD with the thrombus (t) along the wall of the LAD. The upper pictures (A–E) show the respective IVUS cross sections corresponding with A–E in the longitudinal reconstruction. Picture D shows thrombus crossing the first septal branch.