Beyond Angiography: Intracoronary Imaging Revealing a Left Anterior Descending (LAD) Clot in a 45-Year-Old Male Patient

Intravascular imaging has become an invaluable adjunct in the evaluation of ambiguous coronary lesions, particularly when conventional angiography is inconclusive. We report the case of a previously healthy 45-year-old man who presented with acute chest pain and elevated dynamic troponin levels, but without ischemic changes on electrocardiography. His initial invasive coronary angiography revealed a filling defect in the proximal left anterior descending (LAD) artery, which raised the suspicion of an intracoronary thrombus. To further characterize the lesion, intravascular ultrasound (IVUS) and optical coherence imaging (OCT) were performed. Optical coherence tomography (OCT) was performed for clarification and demonstrated a ruptured atherosclerotic plaque with surface irregularity, accompanied by a secondary red thrombus (a thrombus rich in red blood cells and fibrin), as opposed to an isolated primary LAD thrombus. This finding directly influenced the treatment strategy and enabled optimized stent apposition, expansion, and deployment. The case underscores the value of OCT in resolving diagnostic uncertainty when angiographic appearances are equivocal, ensuring an accurate diagnosis and guiding appropriate intervention. In addition to this, OCT-guided percutaneous coronary intervention also markedly improves accuracy in stent deployment, ensuring optimal patient outcomes.