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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 55-56

Iatrogenic Left Main Coronary Artery Dissection During Transradial Primary Percutaneous Intervention (PPCI); A Case Report


1 Assistant Professor, Department of Cardiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India
2 Associate Professor, Department of Cardiology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna - 14, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Pankaj Kumar
Assistant Professor, Department of Anaesthesiology & Critical Care, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna -14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Primary Percutaneous Intervention (PPCI) is the standard of care in ST elevation Myocardial Infarction (STEMI) if it can be done in a timely fashion. The growing use of the transradial approach for primary percutaneous coronary interventions has been shown to decrease the risk of major vascular complications. However, in this case report, we describe an iatrogenic left main artery dissection during transradial PPCI, which is a catastrophic complication, successfully treated with multiple stents.

Keywords: angioplasty; complications; left main dissection; percutaneous coronary intervention; Radial approach; stent


How to cite this article:
Kumar P, Tripathi N, Kumar N. Iatrogenic Left Main Coronary Artery Dissection During Transradial Primary Percutaneous Intervention (PPCI); A Case Report. J Indira Gandhi Inst Med Sci 2017;3:55-6

How to cite this URL:
Kumar P, Tripathi N, Kumar N. Iatrogenic Left Main Coronary Artery Dissection During Transradial Primary Percutaneous Intervention (PPCI); A Case Report. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:55-6. Available from: http://www.jigims.co.in/text.asp?2017/3/2/55/303151




  Introduction Top


Percutaneous coronary stenting procedure for coronary artery disease is common but can sometimes result in life threatening complications. In recent years, the transradial approach for percutaneous coronary interventions has become more widespread. This approach decreases the risk of major vascular complications. Iatrogenic left main dissection during coronary catheterization remains a rare, but still a life threatening condition.


  Case Report Top


A 46 year-old, hypertensive, chronic smoker presented with acute chest pain for last 6 hours in emergency. He had family history of hypertension and diabetes. His resting electrocardiogram (ECG) revealed ST elevation in leads V4-V6. The transthoracic echocardiogram showed regional wall motion abnormalities (RWMA) in posterior and lateral wall, left ventricular (LV) relaxation abnormality and ejection fraction of 35%. Coronary angiography was done that showed totally occluded left circumflex (LCX) artery and significant plaque with 90% obstruction in the left anterior descending coronary artery proximal to the origin of the first septal branch.

Patient was already given loading dose of ticagrelor and aspirin. Pre-procedure pulse rate was 100/min, noninvasive blood pressure 140/90 mmHg, and SpO2 10 0% on room air. Coronary angiography was performed through the right transradial approach. Following local anesthesia, the radial artery was punctured with a 20- gauge needle and cannulated with a soft, 0.025” straight guidewire. A 6 Fr, 23 cm radial sheath (Terumo Corporation, Tokyo,Japan) was placed. Intra-arterial verapamil (2.5 mg), nitroglycerin (200 mg) and 5000 units of unfractionated heparin were administered.

Angiography was done with a diagnostic 5 Fr Optitorque Tig catheter (Terumo corporation,Japan) which revealed Normal Right Coronary Artery(RCA). The left coronary system was engaged with the same catheter which showed a normal left main (LM) coronary artery and totally occluded LCX just after origin and 90 % lesion in mid LAD. The LCX lesion was crossed with hydrophilic 0.014 soft tip PTCA wire (Whisper ES) and lesion was dilated with 2.0×10 angioplasty balloon catheter. Antegrade flow was restored in LCX artery with TIMI- II flow. It was then stented with zotarilimus eluting stent (RESOLUTE 2.5×18) at 12 ATM. There was TIMI-3 flow and well expanded stent struts was railroaded over it to place the stent at LAD after balloon dilatation.

The patient had some relief in chest pain but there was drop in blood pressure to 100 mm Hg. As he was having severe LV dysfunction it was decided to treat the LAD lesion also. The lesion was crossed with 0.014 soft tip PTCA wire (BMW) and pre dilated with 2.0×10 PTCA balloon at 10 ATM. It was then stented with another zotarilimus eluting stent (RESOLUTE 2.75×18 mm) at 14 atm. Patient continued to have chest pain and there was further drop in blood pressure. RAO cranial view showed significant decrease in left main artery diameter with patent stents in LAD and LCX. Oxygen, fluids and analgesia were administered.

Noradrenaline infusion was added to maintain coronary perfusion. After careful interpretation of the angiographic images, the diagnosis of iatrogenic dissection of the LM coronary artery was made.

The case was discussed in emergency between the interventional cardiologists and anaesthesiologist. Bail out Percutaneous intervention (PCI) was decided upon as the therapeutic option of choice over coronary bypass graft surgery (CABG) on IABP support.


  Procedure Top


We stented the left main coronary artery with zotarilimus eluting stent (4.0× 12 mm) at 14 ATM. There was improvement in the coronary flow. The left main stent was further post dilated with 4.5×9 mm non compliant PTCA balloon at 20 ATM to achieve the maximal possible diameter of the stent. Post stent implantation there was relief of chest pain and blood pressure started to improve. He was kept in coronary care unit (CCU) for 2 days where he was weaned from inotropes. His further recovery was uneventful and he was discharged on 5th day after the procedure.


  Discussion Top


Percutaneous transluminal coronary angioplasty is very popular and is being used with increasing success to dilate proximal as well as distal coronary artery. Though the modern imaging technique has increased the success rate of the procedure, it is not always safe. Depending on the extent of the dissection flap and the resulting luminal obstruction, the clinical manifestation varies from an asymptomatic angiographic finding to a complete hemodynamic collapse due to the abrupt closure of the LM.

The original National Heart, Lung and Blood Institute classification system for intimal tears is based upon their angiographic appearances and is graded from type A through F.[1]

A simplified and more practical classification, though, has been proposed, based on the extension of the dissection flap: a localized dissection without extension into the LAD or LCX is defined as type I; extension of the dissection from the LM into the LAD or LCX is defined as type II; and extension of the dissection flap into the aortic root is classified as type III. While type I dissections were associated with excellent outcomes (no hemodynamic instability nor in-hospital death), type III dissections had 100% in-hospital mortality.[2]

Conservative therapy is considered in a minority of the cases, and only in selected stable patients with localized dissections and TIMI III flow. Treatment options for this complication include intracoronary stenting and emergency CABG. Although CABG can be successfully performed, prolonged periods of ischemia often culminate in severe left ventricular dysfunction and death[3] LM stenting with a drug-eluting stent and CABG have shown favorable long-term results for stable coronary artery disease, with similar rates of death and major adverse cardiovascular events during long-term follow up.[4] Both treatment options are valid in the case of an acute LM dissection and should be weighed against each other in terms of the extension of the dissection, the patient’s hemodynamic status, technical feasibility, prompt treatment availability, and the operator’s experience.[5]

If PCI is chosen, wiring the true lumen of the dissection is important , because inadvertent stenting of the false lumen will completely occlude the coronary artery, with dramatic hemodynamic consequences ultimately resulting in the patient’s death.[6]

Patients were more likely to undergo CABG if they were stable and had multivessel disease.


  Conclusion Top


Several lessons can be learnt from this case. First, it obliges us to remember that coronary angiography remains an invasive investigation with rare but life-threatening complications. So resuscitation measures and intra aortic balloon pump should be readily available.

Second, all catheters must be manipulated cautiously, especially when engaging the LM. Injections should only be made when catheters are properly placed and when normal pressures have been identified.

Third, in the unlucky situation of an iatrogenic LM dissection, prompt diagnosis and therapy must be initiated, and the most experienced colleagues and surgeons should be alerted.

Fourth, if available and if tolerated by the patient, intravascular ultrasound (IVUS) can help confirm the correct position of the wire in the true lumen, determine the extension of the dissection, and guide stent sizing.



 
  References Top

1.
Rogers JH, Lasala JM. Coronary artery dissection and perforation complicating percutaneous coronary intervention. J Invasive Cardiol. 2004; 16: 493-9.  Back to cited text no. 1
    
2.
Eshtehardi P, Adorjan P, Togni M, et al. Iatrogenic left main coronary artery dissection: incidence, classification, management, and long-term follow-up. Am Heart J. 2010; 159: 1147- 53.  Back to cited text no. 2
    
3.
Curtis MJ, Traboulsi M, Knudtson ML, Lester WM: Left main coronary artery dissection during cardiac catheterization. Can J Cardiol 1992;8: 725-8.  Back to cited text no. 3
    
4.
Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary- artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009; 360: 961-72.  Back to cited text no. 4
    
5.
Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011; 364: 1718-27.  Back to cited text no. 5
    
6.
Suarez-Mier MP, Merino JL. False lumen stent placement during iatrogenic coronary dissection. Cardiovasc Pathol. 2013; 22: 176-7.  Back to cited text no. 6
    




 

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Introduction
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