OCT Findings from a Spontaneously Recanalized Coronary Thrombus Treated with a Drug-Coated Balloon

Background: Spontaneous recanalized coronary thrombus (SRCT) is an uncommon and often underrecognized coronary pathology that may be angiographically subtle despite having functional significance. Optical coherence tomography (OCT) enables accurate diagnosis and treatment planning. However, optimal treatment strategies remain incompletely defined. Materials and Methods: A 55-year-old man presenting with severe exertional dyspnea, atypical chest pain episodes, and abnormal stress echocardiography underwent invasive coronary assessment with angiography, fractional flow reserve (FFR), and OCT. An SRCT of the left anterior descending artery (LAD) was identified and treated using OCT-guided lesion preparation followed by sirolimus-coated drug-coated-balloon (DCB) angioplasty. Results: Although there was only moderate angiographic disease, a functional assessment confirmed significant ischemia. OCT revealed a characteristic honeycomb morphology. Post-procedural OCT demonstrated satisfactory lumen gain, with preserved vessel integrity. Follow-up imaging showed vessel-healing and late lumen enlargement, and the patient remained asymptomatic. Conclusion: OCT-guided drug-coated-balloon angioplasty may be an effective “leave-nothing-behind” strategy for selected SRCT lesions, highlighting the importance of intracoronary imaging beyond angiography.