J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S VO L . 1 1 , N O . 1 9 , 2 0 1 8

ª 2 0 1 8 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N

P U B L I S H E D B Y E L S E V I E R

IMAGES IN INTERVENTION

Histopathologic Insights Into theHoneycomb-Like Structure in theCoronary Artery

In Vivo Multimodality Imaging Assessment WithDirectional Coronary Atherectomy

Satoshi Suzuki, MD,a Yohei Sotomi, MD, PHD,a Shimpei Nakatani, MD, PHD,a Akio Hirata, MD, PHD,a

Hiroyuki Hao, MD, PHD,b Masahiko Tsujimoto, MD, PHD,c Hiromi Tsuji, MD,c Ichiro Shiojima, MD, PHD,d

Yasushi Sakata, MD, PHD,e Atsushi Hirayama, MD, PHD,a Yoshiharu Higuchi, MD, PHDa

A 50-year-old woman diagnosed with vaso-spastic angina presented to our hospitalwith repeated typical chest pain. The pa-

tient experienced cardiac arrest 14 years previouslybecause of the vasospasm (Figure 1A). Althoughthe patient was prescribed multiple medicationsfor more than 10 years, the symptom was still un-controllable. Recent coronary angiography revealedsevere vasospasm (Figure 1B) and irregular linearfilling defects and haziness, which also existed 14years previously (Figure 1A0), at a proximal part ofthe right coronary artery (Figures 1C and 1C0). Opticalcoherence tomography revealed a honeycomb-likestructure with multiple intraluminal spiral channels(Figures 1D to 1H, Online Video 1a), separated by tis-sue with high signal light intensity and low lightattenuation, consistent with fibrous tissue. Three-dimensional reconstruction of the optical coherencetomographic images illustrated 4 different intra-coronary lumens (Figures 1E0 to 1H0 and 1I, OnlineVideo 1d). Intravascular ultrasound demonstrated asmall plaque burden without positive remodelingat the lesion (Figures 1E00 to H00, Online Video 1b).

ISSN 1936-8798/$36.00

From the aDepartment of Cardiology, Osaka Police Hospital, Osaka, Japan;

thology and Microbiology, Nihon University School of Medicine, Tokyo, Japan

Hospital, Osaka, Japan; dDepartment of Medicine II, Kansai Medical Unive

diovascular Medicine, Osaka University Graduate School of Medicine, Osaka,

relationships relevant to the contents of this paper to disclose.

Manuscript received June 25, 2018; accepted July 3, 2018.

Coronary angioscopy demonstrated septa coveredwith white stable intima without red thrombus(Figure 1J, Online Video 1c). The septum wasbiopsied by directional coronary atherectomy(Figures 2A, 2B, 2A0, and 2B0). Histopathologic assess-ment of the septa demonstrated the bilateralendothelial layers with smooth muscle cells inbetween, without atheromatous plaque. Consideringthe patient’s background, we speculate that recanal-ized mural thrombus induced by vasospasm oranomaly could be possible etiologies ratherthan recanalized embolic thrombus or healedplaque rupture (Figures 2C to 2E sample 1;Figures 2F to 2H, sample 2) (1–4). We treated thelesion with 2 everolimus-eluting stents (Synergy,3.0 � 28 and 3.5 � 28 mm; Boston Scientific, Natick,Massachusetts), successfully relieving the repeatedsymptom.

The present case would be the first report toshow the in vivo histopathologic evaluation of theseptum of honeycomb-like coronary structure. Inseveral previous reports (1–4), thrombus recanali-zation was considered a cause of the intriguing

https://doi.org/10.1016/j.jcin.2018.07.014

bDivision of Human Pathology, Department of Pa-

; cDepartment of Diagnostic Pathology, Osaka Police

rsity, Hirakata, Japan; and the eDepartment of Car-

Japan. The authors have reported that they have no

FIGURE 1 Intracoronary Imaging Assessment of the Honeycomb-Like Structure in the Right Coronary Artery

Cine angiography 14 years previously (A) with magnified view (A0), at baseline with vasospasm (B), and after nitrate administration (C) with

magnified view (C0) is presented. Optical coherence tomography demonstrated a honeycomb-like structure (D, longitudinal view; E to H,

cross sections with matched images from intravascular ultrasound [E00 to H00]; Online Videos 1a and 1b). Four different lumens are color-coded

in the schematic cartoon (E0 to H0) and corresponding 3-dimensional optical coherence tomographic reconstruction (I) (Online Video 1d).

Coronary angioscopy demonstrated septa covered with white stable intima without red thrombus (J) (Online Video 1c). SB ¼ side branch.

Suzuki et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 1 , N O . 1 9 , 2 0 1 8

Histopathology of Coronary Honeycomb-Like Structure O C T O B E R 8 , 2 0 1 8 : e 1 5 7 – 9

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structure, but without histological assessment.The present histopathologic analysis may providemore in-depth insights into possible etiologiesof this unique and rare structure in coronaryarteries.

ADDRESS FOR CORRESPONDENCE: Dr. YoheiSotomi, Department of Cardiology, Osaka PoliceHospital, 10-31, Kitayama, Tennoji, Osaka 543-0035,Japan. E-mail: sotomiyohei@gmail.com.

FIGURE 2 Histopathology of the Septa Resected by Directional Coronary Atherectomy

Matched optical coherence tomographic images pre–directional coronary atherectomy (DCA) (A,B) and post-DCA (A0,B0) clearly indicated that

DCA successfully biopsied the septa without severe complication. Histopathologic assessment of the septa (sample 1, C to E; sample 2, F to H;

C and F, hematoxylin and eosin stain; D and G, Masson’s trichrome stain; E, CD31 immunostain; H, Verhoeff-van Gieson stain) demonstrated

the bilateral endothelial layers (black arrowhead, E) and bilateral elastic laminas (black arrowhead, H) with smooth muscle cells in between,

without atheromatous plaque.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 1 , N O . 1 9 , 2 0 1 8 Suzuki et al.O C T O B E R 8 , 2 0 1 8 : e 1 5 7 – 9 Histopathology of Coronary Honeycomb-Like Structure

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RE F E RENCE S

1. Kang SJ, Nakano M, Virmani R, et al. OCT find-ings in patients with recanalization of organizedthrombi in coronary arteries. J Am Coll Cardiol Img2012;5:725–32.

2. Toutouzas K, Karanasos A, Stathogiannis K,et al. A honeycomb-like structure in the leftanterior descending coronary artery: demonstra-tion of recanalized thrombus by optical coherencetomography. J Am Coll Cardiol Intv 2012;5:688–9.

3. Koyama K, Yoneyama K, Mitarai T, et al. In-stentprotrusion after implantation of a drug-eluting stentin a honeycomb-like coronary artery structure: com-plete resolution over 6months and the role of opticalcoherence tomography imaging in the diagnosis andfollow-up. J Am Coll Cardiol Intv 2014;7:e39–40.

4. Musashi M, Tada N, Uemura N, et al. Multivesselhoneycomb-like structurefinding inoptical coherencetomography. J Am Coll Cardiol Intv 2014;7:e7–8.

KEY WORDS coronary angioscopy,directional coronary atherectomy,histopathology, honeycomb-like structure,intravascular ultrasound, optical coherencetomography

APPENDIX For a supplemental video,please see the online version of this paper.