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(Circulation. 2001;103:778.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

"Black Hole"

Echolucent Restenotic Tissue After Brachytherapy

Marco T. Castagna, MD; Gary S. Mintz, MD; Neil Weissman, MD; Akiko Maehara, MD; Gerard Finet, MD; Ron Waksman, MD

From the Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, Washington Hospital Center, Washington, DC.

In January 2000, a 56-year-old woman was treated with rotational atherectomy and adjunct balloon angioplasty because of multiple episodes of in-stent restenosis of the right coronary artery. She was then enrolled in the open-label brachytherapy protocol WRIST PLUS (Washington Radiation for In-Stent Restenosis Trial with 6 months of Plavix), which consisted of intracoronary -radiation followed by 75 mg/d clopidogrel for a period of 6 months. Six months later, angiography and intravascular ultrasound (IVUS) were performed (Figure). She had recurrent in-stent restenosis extending proximal (between the dark arrows on the angiogram) and distal to the stented segment. The IVUS imaging of this in-stent restenosis area proximal to the stent showed echolucent (dark) tissue (double white arrows). The recurrent lesion was treated with restenting.

View larger version (70K): [in this window] [in a new window]   Figure 1. Black arrows in angiogram (top) correspond to segment of restenotic right coronary artery depicted in IVUS imaging sequence (bottom). IVUS images are displayed from distal (on left) to proximal (on right). As indicated, individual images are 2.5 mm apart to illustrate a 15-mm length of right coronary artery proximal to stent. Each image contains significant echolucent tissue (double white arrows). Tissue closer to ultrasound catheter and closer to adventitia is more echogenic.

Previous studies have shown that in-stent neointimal hyperplasia consists predominantly of spindle-shaped mesenchymal cells (-actin–positive smooth muscle cells) with very little collagen and elastin.^{1 2 3 4} The corresponding IVUS image is hypoechoic but not echolucent. Brachytherapy is a promising alternative for treating in-stent restenosis. The echolucent appearance of the restenotic tissue in the current case is an unusual phenomenon in IVUS imaging. This has been termed a "black hole." We speculate that this black hole of echolucent tissue is caused by the fact that the tissue is acellular and necrotic and lacks connective tissue elements.

Footnotes

Reprint requests to Ron Waksman, MD, 110 Irving Street NW, Suite 4B1, Washington, DC 20010.

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

References

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2. Farb A, Sangiorgi G, Carter AJ, et al. Pathology of acute and chronic coronary stenting in humans. Circulation. 1999;99:44–52.[Abstract/Free Full Text]

3. Kornowski R, Hong MK, Tio FO, et al. In-stent restenosis: contributions of inflammatory response and arterial injury to neointimal hyperplasia. J Am Coll Cardiol. 1998;31:224–230.[Abstract/Free Full Text]

4. Carter AJ, Laird JR, Kufs WM, et al. Coronary stenting with a novel steel balloon-expandable stent: Determinants of neointimal formation and changes in arteria geometry after placement in an atherosclerotic model. J Am Coll Cardiol. 1996;27:1270–1277. [Abstract]

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