Stenting the Right, Sparing the Left: Optical Coherence Tomography–Guided Management of Simultaneous Multivessel Coronary Thrombosis

Simultaneous multivessel coronary thrombosis is uncommon, and its optimal management is undefined, particularly when one culprit is non-occlusive. Optical coherence tomography (OCT) can distinguish plaque rupture from erosion and thereby identify lesions amenable to a stent-sparing, antithrombotic strategy. We report a 34-year-old smoker of Mongolian origin who sustained an inferior myocardial infarction from simultaneous thrombosis of the right coronary artery (RCA, totally occluded) and the proximal left anterior descending artery (LAD, non-occlusive). After emergency thromboaspiration and stenting of the RCA at the referring center, he was transferred to our institution. Because thrombus persisted in the right marginal branch and the LAD, intracoronary imaging was deferred until the acute thrombotic phase had settled. Day 10 OCT demonstrated LAD plaque erosion; a stent-sparing strategy was adopted, and the still-thrombotic RCA territory was left uninstrumented, under intensive antithrombotic therapy. By Day 28, both vessels had resolved, with a healed, layered LAD plaque on co-registered OCT, and RCA stent under-expansion was optimized. OCT-guided, vessel-by-vessel individualization permitted safe conservative management and avoided unnecessary stenting.