Coronary computed tomography angiography (CCTA) scanning was performed in a 53-year-old woman, who presented to the Cardiology Department with typical retrosternal pain on exertion persisting for 6 months. A heterogeneous lesion (~80% stenosis) was found in the proximal left anterior descending artery (LAD) (Figures 1 A and B). Two bright dots of contrast in its main burden were interpreted as ulcerations (Figure 1 C, white arrows), which led to the suspicion of plaque rupture.

Subsequent coronary catheterization revealed significant stenosis in the proximal LAD with no signs of lesion complexity (Figure 1 D). Unexpectedly, the third consecutive injection of contrast medium resulted in sudden occlusion of the vessel at the lesion site with TIMI 0 flow (Figures 1 E and F). Fortunately, an immediate attempt of recanalization was successful and blood flow was restored. After predilatation an everolimus-eluting 2.5/20 mm stent was implanted in the lesion site resulting in TIMI 3 flow.

During observation of the patient in the intensive care unit, the chest pain recurred once, with transient ECG evidence of myocardial ischemia in leads V4-V6. However, control MSCT examination confirmed the good result of PCI. Further follow-up was uneventful. Echocardiography revealed apical hypokinesis and the cardiac MRI performed a month later confirmed a post-infarct scar in the apical segment of the heart.

We suppose that the sudden closure of the previously damaged vessel segment with unstable ruptured plaque was triggered by the rapid flow of the contrast medium. Since it is possible to detect silent ruptured plaques in CCTA, such findings should incline the operators to perform very careful contrast injection in order to prevent serious complications.


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