Atherosclerotic plaque healing: mechanisms and clinical relevance

Abstract Atherosclerotic plaque healing is a dynamic biological mechanism that occurrs after plaque disruption and represents an endogenous reparative response within the atherosclerotic lesion. This process unfolds through three partially overlapping phases: endogenous thrombus lysis, granulation tissue formation, and re-endothelialization. Through the coordinated interaction of circulating cells, vascular wall components, and soluble mediators, plaque healing promotes fibrous repair and structural stabilization of the disrupted plaque. For many years, plaque healing remained primarily a histopathological observation described in post-mortem studies. The advent of high-resolution intracoronary imaging, particularly optical coherence tomography, has enabled in vivo visualization of the characteristic layered morphology of healed plaques, providing direct clinical confirmation of these early pathological findings. These observations have significantly improved our understanding of the clinical significance of plaque healing. Healed plaques are more frequently observed in patients with chronic coronary syndromes, supporting the concept that healing contributes to plaque stabilization. At the same time, recurrent cycles of plaque disruption followed by repair may lead to progressive luminal narrowing, thereby contributing to the long-term progression of coronary atherosclerosis. This review provided an updated overview of the clinical significance and implications of healed plaques in coronary artery disease, the mechanisms underlying plaque healing, and examines emerging intracoronary and non-invasive imaging modalities that allow their in vivo identification.