PMC9970812_01
The initial coronary angiogram (A) obtained from the patient showed severe stenosis in the proximal left anterior descending artery, which resolved after administering combination treatment consisting of directional coronary atherectomy and balloon angioplasty (B). A coronary angiogram taken 8 months after treatment (C) showed no stenosis in the treated legion.
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Therefore, intravascular ultrasound (IVUS)-guided PCI was performed for the proximal LAD stenosis (Fig. 1A). B. Braun, Melsungen, Germany) angioplasty was performed, which achieved an optimal result without any major coronary dissection nor coronary flow disturbance (Fig. 1B). A follow-up CAG 8 months after the PCI showed no restenosis in the treated lesion (Fig. 1C).
Comparison of the intravascular ultrasound (IVUS) images in the culprit lesion between (A) pre-directional coronary atherectomy (DCA) and (B) post-DCA. The red asterisks indicate intraplaque hemorrhage. The plaque region resected by DCA was indicated by yellow arrows in the initial IVUS images.
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IVUS showed that the culprit lesion consisted of non-lipidic plaque, including a superficial crescent-shaped echolucent region (Fig. 2A). IVUS post-DCA showed the coronary plaque volume to significantly decrease from 89% to 43% (Fig. 2B).
Histopathological findings of the specimens, including low-power images (A-D) and high-power images (A'-D') of the dotted box in the low-power images of Hematoxylin and Eosin staining, glycophorin-A staining, CD68 immunostaining, and immunostaining of matrix metalloproteinase-9 (MMP-9). The intense staining of glycophorin-A suggested the presence of intraplaque hemorrhage. Moreover, a large number of CD68-positive cells with MMP-9 expression was observed in the culprit plaque. The arrowheads in the low-power images indicate intraplaque hemorrhage, which is magnified in the high-power images.
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These findings therefore indicated the presence of a vulnerable plaque (Fig. 3).
A flash glucose monitoring system showed large glucose fluctuations and asymptomatic hypoglycemia.
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Although the patient had no typical hypoglycemic symptoms, we evaluated the patient's daily glycemic profile via FGM, which confirmed extremely large GFs (mean amplitude of glycemic excursion: 121.8 mg/dL) and asymptomatic hypoglycemia both post-meal and during middle of the night measurements (a latent severe glycemic disorder) (Fig. 4).