Multivessel Percutaneous Coronary Intervention in a Patient With Woven Coronary Artery Anomaly

A 41-year-old man with morbid obesity, type 2 diabetes mellitus, dyslipidemia, and unprovoked right lower extremity deep venous thrombosis reported exertional chest discomfort for almost a month. As part of his evaluation, he underwent coronary computed tomography angiogram that demonstrated ≥70% stenosis in the mid left anterior descending artery (LAD) with noncalcified atherosclerosis. The proximal right coronary artery (RCA) had noncalcified atherosclerosis with 25%-49% stenosis.Coronary angiography revealed severe tubular stenosis in the mid segment of the LAD artery consisting of thin channels with Thrombolysis in Myocardial Infarction grade 3 flow. The RCA encompassed small woven microchannels in the proximal to mid vessel (Figure 1A, B, Supplemental Videos 1 and 2). Optical coherence tomography (OCT) in the LAD and RCA demonstrated honeycomb-appearing lesions (Figure 1C, D, Supplemental Videos 3 and 4). The pressure wire could not be advanced across the RCA lesion despite multiple attempts. After a discussion with the patient and the referring provider, we proceeded with percutaneous coronary intervention (PCI). PCI was carried out over the workhorse wire (All Star; Abbott Vascular) with a 3.0 ​× ​30 ​mm drug-eluting stent into the LAD and 3.5 ​× ​38 ​mm drug-eluting stent in the RCA (Figure 1E, F, Supplemental Videos 5 and 6). OCT showed optimal stent expansion and apposition with no edge dissection (Figure 1G, H, Supplemental Videos 7 and 8). There was no apparent immediate complication, and the patient was discharged home on the same day of his procedure. He was subsequently seen in the clinic 1 ​month later and was free of angina.DiscussionWoven coronary anomaly is a rare anomaly where a segment of the coronary artery consists of small twisted microchannels separated by fibrous septa that reconstitute later to form a single lumen with preserved distal flow.1Sane D.C. Vidaillet H.J.J. “Woven” right coronary artery: a previously undescribed congenital anomaly.Am J Cardiol. 1988; 61: 1158Abstract Full Text PDF PubMed Scopus (28) Google Scholar,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar Although sometimes considered a benign variant,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar evidence suggests that these microchannels can be clinically significant and are associated with ischemia.3Yorifuji H. Shutta R. Egami Y. Nishino M. Tanouchi J. Woven coronary artery anomaly.JACC Case Rep. 2020; 2: 1698-1699Crossref PubMed Scopus (0) Google Scholar,4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar The pathophysiology is poorly understood, and it remains unclear if this is a distinct congenital entity or thrombus after spontaneous coronary dissection. The thin twisted channels that are present from birth or caused by a spontaneous dissection give a rise to stasis or accelerated atherosclerosis due to shear stress and subsequent thrombus formation.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar In our patient, we opted to intervene due to the lack of other etiologies responsible for his symptoms, the likelihood of hemodynamic significant stenosis across these channels, and the uncertainty about future coronary events associated with this condition.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google Scholar,6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar The percutaneous approach was chosen because of low complexity of coronary disease, high likelihood of obtaining optimal results with nonsurgical means, and the patient’s preference to avoid surgery.Most commonly it affects the RCA, but involvement of the left coronary artery has also been reported.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar Involvement of 2 or more vessels which our patient had was unusual, and PCI was rarely performed.6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar A honeycomb, Swiss cheese, or spider web appearance on OCT is highly specific.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google ScholarWiring through intracoronary thrombus can be challenging. Using a workhorse wire with hydrophilic coating, such as Sion (Asahi Intecc) or BMW (Abbott), polymer-jacketed wire, such as Fielder FC or Sion black (Asahi), microcatheters or over-the-wire balloon to enhance the wire support and penetration, or combinations of the above might be needed for successful crossing of the lesion.The inability to pass the pressure wire in our case was thought to be the consequence of poor handling properties of these wires and possibly the inability to finesse and select the microchannel that connects to the distal vessel. The Hi-Torque All Star wire is a support wire with a soft tip, is highly torquable, and provides excellent support to facilitate equipment delivery. It has a unique feature in comparison to other support wires that allows for primary wiring.Our patient continues to do well at 1-month follow-up; however, the risk of recurrence of this anomaly in the future is unknown due to a scarcity of long-term follow-up. A 41-year-old man with morbid obesity, type 2 diabetes mellitus, dyslipidemia, and unprovoked right lower extremity deep venous thrombosis reported exertional chest discomfort for almost a month. As part of his evaluation, he underwent coronary computed tomography angiogram that demonstrated ≥70% stenosis in the mid left anterior descending artery (LAD) with noncalcified atherosclerosis. The proximal right coronary artery (RCA) had noncalcified atherosclerosis with 25%-49% stenosis. Coronary angiography revealed severe tubular stenosis in the mid segment of the LAD artery consisting of thin channels with Thrombolysis in Myocardial Infarction grade 3 flow. The RCA encompassed small woven microchannels in the proximal to mid vessel (Figure 1A, B, Supplemental Videos 1 and 2). Optical coherence tomography (OCT) in the LAD and RCA demonstrated honeycomb-appearing lesions (Figure 1C, D, Supplemental Videos 3 and 4). The pressure wire could not be advanced across the RCA lesion despite multiple attempts. After a discussion with the patient and the referring provider, we proceeded with percutaneous coronary intervention (PCI). PCI was carried out over the workhorse wire (All Star; Abbott Vascular) with a 3.0 ​× ​30 ​mm drug-eluting stent into the LAD and 3.5 ​× ​38 ​mm drug-eluting stent in the RCA (Figure 1E, F, Supplemental Videos 5 and 6). OCT showed optimal stent expansion and apposition with no edge dissection (Figure 1G, H, Supplemental Videos 7 and 8). There was no apparent immediate complication, and the patient was discharged home on the same day of his procedure. He was subsequently seen in the clinic 1 ​month later and was free of angina. DiscussionWoven coronary anomaly is a rare anomaly where a segment of the coronary artery consists of small twisted microchannels separated by fibrous septa that reconstitute later to form a single lumen with preserved distal flow.1Sane D.C. Vidaillet H.J.J. “Woven” right coronary artery: a previously undescribed congenital anomaly.Am J Cardiol. 1988; 61: 1158Abstract Full Text PDF PubMed Scopus (28) Google Scholar,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar Although sometimes considered a benign variant,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar evidence suggests that these microchannels can be clinically significant and are associated with ischemia.3Yorifuji H. Shutta R. Egami Y. Nishino M. Tanouchi J. Woven coronary artery anomaly.JACC Case Rep. 2020; 2: 1698-1699Crossref PubMed Scopus (0) Google Scholar,4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar The pathophysiology is poorly understood, and it remains unclear if this is a distinct congenital entity or thrombus after spontaneous coronary dissection. The thin twisted channels that are present from birth or caused by a spontaneous dissection give a rise to stasis or accelerated atherosclerosis due to shear stress and subsequent thrombus formation.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar In our patient, we opted to intervene due to the lack of other etiologies responsible for his symptoms, the likelihood of hemodynamic significant stenosis across these channels, and the uncertainty about future coronary events associated with this condition.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google Scholar,6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar The percutaneous approach was chosen because of low complexity of coronary disease, high likelihood of obtaining optimal results with nonsurgical means, and the patient’s preference to avoid surgery.Most commonly it affects the RCA, but involvement of the left coronary artery has also been reported.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar Involvement of 2 or more vessels which our patient had was unusual, and PCI was rarely performed.6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar A honeycomb, Swiss cheese, or spider web appearance on OCT is highly specific.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google ScholarWiring through intracoronary thrombus can be challenging. Using a workhorse wire with hydrophilic coating, such as Sion (Asahi Intecc) or BMW (Abbott), polymer-jacketed wire, such as Fielder FC or Sion black (Asahi), microcatheters or over-the-wire balloon to enhance the wire support and penetration, or combinations of the above might be needed for successful crossing of the lesion.The inability to pass the pressure wire in our case was thought to be the consequence of poor handling properties of these wires and possibly the inability to finesse and select the microchannel that connects to the distal vessel. The Hi-Torque All Star wire is a support wire with a soft tip, is highly torquable, and provides excellent support to facilitate equipment delivery. It has a unique feature in comparison to other support wires that allows for primary wiring.Our patient continues to do well at 1-month follow-up; however, the risk of recurrence of this anomaly in the future is unknown due to a scarcity of long-term follow-up. Woven coronary anomaly is a rare anomaly where a segment of the coronary artery consists of small twisted microchannels separated by fibrous septa that reconstitute later to form a single lumen with preserved distal flow.1Sane D.C. Vidaillet H.J.J. “Woven” right coronary artery: a previously undescribed congenital anomaly.Am J Cardiol. 1988; 61: 1158Abstract Full Text PDF PubMed Scopus (28) Google Scholar,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar Although sometimes considered a benign variant,2Berman A.D. Kim D. Baim D.S. “Woven” right coronary artery: case report and therapeutic implications.Cathet Cardiovasc Diagn. 1990; 21: 258-259Crossref PubMed Scopus (12) Google Scholar evidence suggests that these microchannels can be clinically significant and are associated with ischemia.3Yorifuji H. Shutta R. Egami Y. Nishino M. Tanouchi J. Woven coronary artery anomaly.JACC Case Rep. 2020; 2: 1698-1699Crossref PubMed Scopus (0) Google Scholar,4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar The pathophysiology is poorly understood, and it remains unclear if this is a distinct congenital entity or thrombus after spontaneous coronary dissection. The thin twisted channels that are present from birth or caused by a spontaneous dissection give a rise to stasis or accelerated atherosclerosis due to shear stress and subsequent thrombus formation.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar In our patient, we opted to intervene due to the lack of other etiologies responsible for his symptoms, the likelihood of hemodynamic significant stenosis across these channels, and the uncertainty about future coronary events associated with this condition.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google Scholar,6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar The percutaneous approach was chosen because of low complexity of coronary disease, high likelihood of obtaining optimal results with nonsurgical means, and the patient’s preference to avoid surgery. Most commonly it affects the RCA, but involvement of the left coronary artery has also been reported.4Ayhan S. Ozturk S. Tekelioglu U. Ocak T. Woven coronary artery anomaly associated with acute coronary syndrome.Int J Angiol. 2013; 22: 55-58Crossref PubMed Scopus (8) Google Scholar Involvement of 2 or more vessels which our patient had was unusual, and PCI was rarely performed.6Dallan L.R.P. Dallan L.A.O. Moretti M. Moragas A.B.C. Dallan L.A.P. Jatene F.B. Multivessel woven coronary artery disease.Braz J Cardiovasc Surg. 2021; 36: 825-828Crossref PubMed Scopus (0) Google Scholar A honeycomb, Swiss cheese, or spider web appearance on OCT is highly specific.5Kang S.J. Nakano M. Virmani R. et al.OCT findings in patients with recanalization of organized thrombi in coronary arteries.JACC Cardiovasc Imaging. 2012; 5: 725-732Crossref PubMed Scopus (45) Google Scholar Wiring through intracoronary thrombus can be challenging. Using a workhorse wire with hydrophilic coating, such as Sion (Asahi Intecc) or BMW (Abbott), polymer-jacketed wire, such as Fielder FC or Sion black (Asahi), microcatheters or over-the-wire balloon to enhance the wire support and penetration, or combinations of the above might be needed for successful crossing of the lesion. The inability to pass the pressure wire in our case was thought to be the consequence of poor handling properties of these wires and possibly the inability to finesse and select the microchannel that connects to the distal vessel. The Hi-Torque All Star wire is a support wire with a soft tip, is highly torquable, and provides excellent support to facilitate equipment delivery. It has a unique feature in comparison to other support wires that allows for primary wiring. Our patient continues to do well at 1-month follow-up; however, the risk of recurrence of this anomaly in the future is unknown due to a scarcity of long-term follow-up. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Research reported has adhered to the relevant ethical guidelines. Supplementary materialeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhNzc0MjkxMWM0NWVjMGQ2YWI4OTg3OWRjZmUxNjE3MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.O2PP3wT6hJVlj4uhLFceaeSaU3I3mPibsmsO_cTVdNfbvJrmJk1yiDngg8HPal2j2ixTWuXCTQ49XGuUP7h8CWfUPg6YcenU45b0TzfUlgl6QYHArJCX-mzBeb--RTRcwj_ZTOJd3UZYX9cKNKpYrT3Oh8Hg-y4p0PH4e3ZnQvn7YPeojgMY_QebANXKSQ-nmdljozu-N2meDSldNLvS5vuWJGe811-NSl65D2OhJcu-N7JPJar_TMDZSOjCQEuw5A841peDlAZUjFXXeZXcloZGn_fSMRENUU9yKOTXrBV3uPLkHDxoWAYqR6oIo6nE8R0KptmTlAPV45G_X6C_eg Download .mp4 (1.77 MB) Help with .mp4 files Supplemental Video 1Severe stenosis in the LAD.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4N2YxN2IwMmU1ZTU4ZGNiZWNmZjNlMzBkN2ExYmNhMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.e43IK1QoD5EtnicIYpoIQeJObhJ32RToRNaWVEXgOZDgG3UbMxtN0gXzvLv5PgPGWq-bI31I6km7ZUHj8KcuVFW2gbgyoH_WtI6gpwq6b9s6POdqCf_OfM0RrKbuFxG4Kxyw3OIqHV1gT_ze1674kEGpUBKVqlJGnbJ09J0IcWN1cbFewlbgnragH7ZwgCxGcMFmYp6-xO3BXLD1fSF_EF30K38ULOLYoi0bawsdWYBx3eX2QEf-QIy17cNiJE4Xc7CLmj8TJKLftATvdgkeRW5-1cb8p3Ky-SB1o7V_qRDDc-tmaorw4ROuKGZe_sQ6S6Eachz8i93bTZScQIKIfA Download .mp4 (1.31 MB) Help with .mp4 files Supplemental Video 2Small woven microchannels in the proximal-mid RCA.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0MWNjYWQ3YmEwMjE3MTk2MmI5NDEwYzkyZDQ3NDBmYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.J5iQ1NcI8OmWwExazwhAjkrmTfYIk45EGlHSbwpf8z-dMe5kD6_CakUKDR29KIlg3OZQtu0_7lFO3nt-Gq3qsOKVUuoDpU4NxdTyKFXyJmjAUJkdfQHHUNNaYz9AuWyLRaSmJTT7wb9GEKTal2MiObiRbPJwFlXL8XNMpwRxO_L94LCK3tiymLB_DsQN5dd6ApIvkHNMB7qePBHmxKWoKg3jqkUFq-g4K8l1K_-aGrkE-koK1IZ_mMCBwc52NwV5t5Gvr_k_3QOj4Pc_x2YCTsFvCR6U6L7M5Slj2wHYpyal8r4Yhj5eQXUSGS858U03TUWkZWF5EV5gCYtPuYBONQ Download .mp4 (7.28 MB) Help with .mp4 files Supplemental Video 3OCT of the LAD pre-stenting showing honeycomb appearing lesion (woven microchannels) in the mid vessel.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmZjM0Yjk5NjE1NjdkZmU0M2UzMDA5MGQ3NzYyOWZlMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.hOhiTcNAhPKEBsUfY_oShofRPuB-Y6z5qB7DLXXF_zsQDWu-dbw_u95o5jdcQu521qSUXiGkr2aRpnc1lNDByN9UWjV6zkBanuB-zmAYvZ5a0JAyHBGabvYDYbz-1Dbf1mptuUcXOpJmkkhz-3NhakbkgM4Kude84LJJQknwYmrGUMb-L4VpXJriAHlZ06NuCqT89ENcrfT3X9H1ZtD3rm_VqqamJX3Zdydqak5YkFw_g1WF1_p_gVNYq4aMIGEGR39igwjUSSZjr_Cj9X1N6n9KySKLrVKqb_p1acYEmzZZdelx-uOdb_VnsVipOntMukKDvXMCOu1dlAV857mpPA Download .mp4 (7.26 MB) Help with .mp4 files Supplemental Video 4OCT of the RCA pre-stenting showing honeycomb appearing lesion (woven microchannels) in the proximal-mid vessel.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NDhlODVkNDcxMzMwOWY5NjE0Yzk2YzcxNmY3OGQyNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.H3EwraITIL-rgd83UbWqXI_2ZX4OTojcTjiZyqKAOhc7XatlmvmgiEtySube5hGAIgtUEkfgFGaUTS6lh0F8bleW3m4Up8wrZ2kfUv-zSwlL7pQOsgw9JxcQTpUffA58DaIOiWZe4BP4KVKGCjABu7FiiKeTLxP_JJ2BQ-q6smeWAM3mQVNcCVTyvt97pcBLevGhdEDThYY1NfyevRKM3pSRPwIOHS2AZLkS6AgjnSJfNK70qEgVFV2nznW_ngeHNOwjKK9d-xPy90RlgB900m30J7esLCiF82Ro2pHwOnP5RnTM1VJ6FkAtIDCvxoX3RYRJ9YPD0E-TlMsxLkLrsw Download .mp4 (1 MB) Help with .mp4 files Supplemental Video 5LAD post stent with 3.0 × 30 mm DES and 2 kissing balloons 3.0 × 15 mm in the LAD, and 2.5 × 12 mm in the D1.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZDQwMDcwNGZlOTQ1ZDU0MDI4OWZiNjgzMWM1MTY2YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.HRO2-rbkU7nYypUHWPshu1DzrYpMo4ErxrRSwX77aCSrmsZfWSgSZn9LWlJ6xqgue5z1DO-8Cu1pDcL54C53nCgb1ex4yfzeaWTTguJVvl1xgpNt6r9u5C_bY2JdAF2znoETA5lQ26y0i1n0Ylf6ePTL5_U85kYXzS1wCuc58xHSCU1TrNt2Nu6JdF2n0KYWE83hzk3PGEmpAo4ArQsg9wOG5B62zatK868xRbbs8TRPeH2XwRjHRW5fxTc9rlyyDmMmaeA3h7ACqrsN-mvs50aF3DczzS6KVvU-LPWUSN1DdKws0mDsHAsUt21jpo53dZlv_H4iFrbSTvjnuN1Wug Download .mp4 (1.15 MB) Help with .mp4 files Supplemental Video 6RCA post stent with 3.5 × 38 mm DES.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5OTI0MGQ5YWIwMzlhNWRmYzUzMWI3NGNiMTg2OTQ5ZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.N-OvTpSmWN2gv7u1pHfZMt1ayGykkFRkYZqWGo9aasXBT3sq7OMKxnfHJo8YOnkzRDuaA6gjBmSvCULsSlsBJksoOh9Xrfj7PQlQDFt_kI-yifD2FyJuEF--u0T1deGL51I0Dbx1qteIzH_3baUrZ8mUcO23FWU6YSXVmELayBCHAnF5q0EkraVuapnnwyYz3E9Xxrx01lwRJOOozURkDeYmJ5_cA51pMWTSrxII-8fPdOgyGBt5U6qZ7VP_rLXEE98uYxtLjg9SeD_DljLSwvw-_8vjBSMvRsAcxUPs5IQkopT0Jrz6EQuHCGOvnq9UECLobWFYQWs6ONaeJHXtow Download .mp4 (7.23 MB) Help with .mp4 files Supplemental Video 7OCT of the LAD post stent implantation showing no medial edge dissection, good stent expansion and apposition throughout.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZTg5MWRmNzhjYmMyYTliNmY3NDA1ZTRhNWY0YjBhNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.eqz26Ox_VIulN-vMCJw6OjUl_ofSVEwfIGeabQ9fh5c6sTMGtojnlWRitlo5AtXThrxyGziTbXdtCNAUKnl5OoiRre_k4JHprZoqANbXL02_z1Et9OT_6ho38boLa-M8o1zcxuASY7WKFObI6PIW_SiKmFQb16286ycx19XfaLZ65Vv5px4cvVs7ZS9b6sTlGc--XMIJOWKhGCdYXkXb60RbgtqJM4QiUqlsaZam9M1QisNzNg655A58s5x35hn2DvS4eD8Q2vzpr2kSdaN6ecwVcWaJplK897VN19rfTXlVInIaxXoccFCMS1nOGeqSSo17VyhfBcxJgAy9b-5dWA Download .mp4 (7.16 MB) Help with .mp4 files Supplemental Video 8OCT of the RCA post stent implantation showing no medial edge dissection, good stent expansion and apposition throughout. D1, Diagonal 1; DES, drug eluting stent; LAD, left anterior descending; RCA, right coronary artery; OCT, optical coherence tomography. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhNzc0MjkxMWM0NWVjMGQ2YWI4OTg3OWRjZmUxNjE3MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.O2PP3wT6hJVlj4uhLFceaeSaU3I3mPibsmsO_cTVdNfbvJrmJk1yiDngg8HPal2j2ixTWuXCTQ49XGuUP7h8CWfUPg6YcenU45b0TzfUlgl6QYHArJCX-mzBeb--RTRcwj_ZTOJd3UZYX9cKNKpYrT3Oh8Hg-y4p0PH4e3ZnQvn7YPeojgMY_QebANXKSQ-nmdljozu-N2meDSldNLvS5vuWJGe811-NSl65D2OhJcu-N7JPJar_TMDZSOjCQEuw5A841peDlAZUjFXXeZXcloZGn_fSMRENUU9yKOTXrBV3uPLkHDxoWAYqR6oIo6nE8R0KptmTlAPV45G_X6C_eg Download .mp4 (1.77 MB) Help with .mp4 files Supplemental Video 1Severe stenosis in the LAD.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4N2YxN2IwMmU1ZTU4ZGNiZWNmZjNlMzBkN2ExYmNhMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.e43IK1QoD5EtnicIYpoIQeJObhJ32RToRNaWVEXgOZDgG3UbMxtN0gXzvLv5PgPGWq-bI31I6km7ZUHj8KcuVFW2gbgyoH_WtI6gpwq6b9s6POdqCf_OfM0RrKbuFxG4Kxyw3OIqHV1gT_ze1674kEGpUBKVqlJGnbJ09J0IcWN1cbFewlbgnragH7ZwgCxGcMFmYp6-xO3BXLD1fSF_EF30K38ULOLYoi0bawsdWYBx3eX2QEf-QIy17cNiJE4Xc7CLmj8TJKLftATvdgkeRW5-1cb8p3Ky-SB1o7V_qRDDc-tmaorw4ROuKGZe_sQ6S6Eachz8i93bTZScQIKIfA Download .mp4 (1.31 MB) Help with .mp4 files Supplemental Video 2Small woven microchannels in the proximal-mid RCA.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0MWNjYWQ3YmEwMjE3MTk2MmI5NDEwYzkyZDQ3NDBmYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.J5iQ1NcI8OmWwExazwhAjkrmTfYIk45EGlHSbwpf8z-dMe5kD6_CakUKDR29KIlg3OZQtu0_7lFO3nt-Gq3qsOKVUuoDpU4NxdTyKFXyJmjAUJkdfQHHUNNaYz9AuWyLRaSmJTT7wb9GEKTal2MiObiRbPJwFlXL8XNMpwRxO_L94LCK3tiymLB_DsQN5dd6ApIvkHNMB7qePBHmxKWoKg3jqkUFq-g4K8l1K_-aGrkE-koK1IZ_mMCBwc52NwV5t5Gvr_k_3QOj4Pc_x2YCTsFvCR6U6L7M5Slj2wHYpyal8r4Yhj5eQXUSGS858U03TUWkZWF5EV5gCYtPuYBONQ Download .mp4 (7.28 MB) Help with .mp4 files Supplemental Video 3OCT of the LAD pre-stenting showing honeycomb appearing lesion (woven microchannels) in the mid vessel.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmZjM0Yjk5NjE1NjdkZmU0M2UzMDA5MGQ3NzYyOWZlMCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.hOhiTcNAhPKEBsUfY_oShofRPuB-Y6z5qB7DLXXF_zsQDWu-dbw_u95o5jdcQu521qSUXiGkr2aRpnc1lNDByN9UWjV6zkBanuB-zmAYvZ5a0JAyHBGabvYDYbz-1Dbf1mptuUcXOpJmkkhz-3NhakbkgM4Kude84LJJQknwYmrGUMb-L4VpXJriAHlZ06NuCqT89ENcrfT3X9H1ZtD3rm_VqqamJX3Zdydqak5YkFw_g1WF1_p_gVNYq4aMIGEGR39igwjUSSZjr_Cj9X1N6n9KySKLrVKqb_p1acYEmzZZdelx-uOdb_VnsVipOntMukKDvXMCOu1dlAV857mpPA Download .mp4 (7.26 MB) Help with .mp4 files Supplemental Video 4OCT of the RCA pre-stenting showing honeycomb appearing lesion (woven microchannels) in the proximal-mid vessel.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3NDhlODVkNDcxMzMwOWY5NjE0Yzk2YzcxNmY3OGQyNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.H3EwraITIL-rgd83UbWqXI_2ZX4OTojcTjiZyqKAOhc7XatlmvmgiEtySube5hGAIgtUEkfgFGaUTS6lh0F8bleW3m4Up8wrZ2kfUv-zSwlL7pQOsgw9JxcQTpUffA58DaIOiWZe4BP4KVKGCjABu7FiiKeTLxP_JJ2BQ-q6smeWAM3mQVNcCVTyvt97pcBLevGhdEDThYY1NfyevRKM3pSRPwIOHS2AZLkS6AgjnSJfNK70qEgVFV2nznW_ngeHNOwjKK9d-xPy90RlgB900m30J7esLCiF82Ro2pHwOnP5RnTM1VJ6FkAtIDCvxoX3RYRJ9YPD0E-TlMsxLkLrsw Download .mp4 (1 MB) Help with .mp4 files Supplemental Video 5LAD post stent with 3.0 × 30 mm DES and 2 kissing balloons 3.0 × 15 mm in the LAD, and 2.5 × 12 mm in the D1.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZDQwMDcwNGZlOTQ1ZDU0MDI4OWZiNjgzMWM1MTY2YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.HRO2-rbkU7nYypUHWPshu1DzrYpMo4ErxrRSwX77aCSrmsZfWSgSZn9LWlJ6xqgue5z1DO-8Cu1pDcL54C53nCgb1ex4yfzeaWTTguJVvl1xgpNt6r9u5C_bY2JdAF2znoETA5lQ26y0i1n0Ylf6ePTL5_U85kYXzS1wCuc58xHSCU1TrNt2Nu6JdF2n0KYWE83hzk3PGEmpAo4ArQsg9wOG5B62zatK868xRbbs8TRPeH2XwRjHRW5fxTc9rlyyDmMmaeA3h7ACqrsN-mvs50aF3DczzS6KVvU-LPWUSN1DdKws0mDsHAsUt21jpo53dZlv_H4iFrbSTvjnuN1Wug Download .mp4 (1.15 MB) Help with .mp4 files Supplemental Video 6RCA post stent with 3.5 × 38 mm DES.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5OTI0MGQ5YWIwMzlhNWRmYzUzMWI3NGNiMTg2OTQ5ZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.N-OvTpSmWN2gv7u1pHfZMt1ayGykkFRkYZqWGo9aasXBT3sq7OMKxnfHJo8YOnkzRDuaA6gjBmSvCULsSlsBJksoOh9Xrfj7PQlQDFt_kI-yifD2FyJuEF--u0T1deGL51I0Dbx1qteIzH_3baUrZ8mUcO23FWU6YSXVmELayBCHAnF5q0EkraVuapnnwyYz3E9Xxrx01lwRJOOozURkDeYmJ5_cA51pMWTSrxII-8fPdOgyGBt5U6qZ7VP_rLXEE98uYxtLjg9SeD_DljLSwvw-_8vjBSMvRsAcxUPs5IQkopT0Jrz6EQuHCGOvnq9UECLobWFYQWs6ONaeJHXtow Download .mp4 (7.23 MB) Help with .mp4 files Supplemental Video 7OCT of the LAD post stent implantation showing no medial edge dissection, good stent expansion and apposition throughout.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4ZTg5MWRmNzhjYmMyYTliNmY3NDA1ZTRhNWY0YjBhNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwNzA1MDEzfQ.eqz26Ox_VIulN-vMCJw6OjUl_ofSVEwfIGeabQ9fh5c6sTMGtojnlWRitlo5AtXThrxyGziTbXdtCNAUKnl5OoiRre_k4JHprZoqANbXL02_z1Et9OT_6ho38boLa-M8o1zcxuASY7WKFObI6PIW_SiKmFQb16286ycx19XfaLZ65Vv5px4cvVs7ZS9b6sTlGc--XMIJOWKhGCdYXkXb60RbgtqJM4QiUqlsaZam9M1QisNzNg655A58s5x35hn2DvS4eD8Q2vzpr2kSdaN6ecwVcWaJplK897VN19rfTXlVInIaxXoccFCMS1nOGeqSSo17VyhfBcxJgAy9b-5dWA Download .mp4 (7.16 MB) Help with .mp4 files Supplemental Video 8OCT of the RCA post stent implantation showing no medial edge dissection, good stent expansion and apposition throughout. D1, Diagonal 1; DES, drug eluting stent; LAD, left anterior descending; RCA, right coronary artery; OCT, optical coherence tomography.