Coronary Perforation of Proximal LAD after Debulking for Left Main Coronary Artery Stenosis, Treated with PTEE-covered JoStent

- Operator : Seung-Jung Park

Coronary Perforation of Proximal LAD after Debulking for Left Main Coronary Artery Stenosis, Treated with PTEE-covered JoStent

- Operator : Seung-Jung Park, MD, Phd, Korea

Clinical history
Sixty-two year old man presented with resting chest pain for 3 months. He had hypertension and smoking as coronary risk factors. His baseline ECG showed normal. Treadmill test was positive at early stage. Baseline echocardiogram and cardiac enzymes were normal.
Baseline Coronary Angiography
Initial left coronary angiogram showed left main coronary artery (LMCA) narrowing with involvement of ostial LAD (Figure 1) and right coronary angiogram showed intermediate stenosis.
Procedure
We obtained right common femoral artery access and inserted a 10 F femoral sheath through right femoral artery. The left coronary was engaged with a 10 F JL4 guiding catheter. To perform debulking atherectomy, left main to left anterior descending artery (LAD) was wired with a 0.014 inch SCA-EX (Guidant Corporation, Santa Clara, California) debulking coronary atherectomy (DCA) wire. We thought that proximal and middle portion of LMCA might have heavy atheromatous plaque and be a adequate lesion of DCA. After then, a 7F DCA device (3.5-4.0mm) was advanced into the LMCA lesion, and 11 cuts were made to remove the atheromatous plaque effectively (Figure 2). Angiogram performed immediately after 11 cuts of DCA confirmed the presence of coronary perforation with free flow of contrast into the pericardial space (Figure 3). The vital sign of this patient was stable except sinus tachycardia. We thought that the perforation was not large and could be sealed with polytetrafluoroethylene (PTFE)-coated JoStent (Jomed International AB, Helsingborg, Sweden). A 19-mm long JoStent mounted on a 3.5-mm balloon was deployed at 12 atm over the perforation site (Figure 4). A second 9mm x 4.0 mm NIR stent (Boston Scientific Corporation, Boston, Massachusetts) was placed so as to overlap the JoStent and cover LMCA lesion (Figure 5). Following successful stenting, residual free flow was not founded (Figure 6).
Follow-up after procedure
Echocardiogram immediately after intervention showed minimal pericardial effusion and good left ventricular function without regional wall motion abnormality. Cardiac enzymes were not elevated after intervention. He was discharged with aspirin and ticlopidine. Angiographic follow-up performed 6 months later showed patent JoStent and NIR stent (Figure 7).
Take home message

Because we thought that the initial angiographic finding showed enough information for adequate DCA, we did not get baseline IVUS images. Therefore, we did not notice the vascular remodeling pattern of LMCA and ostial LAD lesion of this case. As we presented our data in ¡®Focus Review¡¯ section of this case, the vascular remodeling pattern might affect the long-term outcome of DCA. Considering the data, we can guess that the ostial LAD lesion of this case might be the lesion with negative vascular remodeling that promoted coronary rupture during aggressive DCA.

In conclusion, we strongly suggest that IVUS should be considered in debulking atherectomy especially in LMCA and ostial LAD lesions to facilitate the effective debulking and choose adequate lesions for debulking.

Comments

  • xubo 2003-07-04 Very important teaching point. I hope Dr.Park could present this stratergy during this year Fuwai meeting. Thank you very much.
  • Seung-Jung Park 2003-07-06 Thank you for your interest.
  • Zheng zhen guo 2003-07-19 OS of LCX and ramus were compromised after the second stent implantation from the image, but the outcomes of 6 months follow up was very good , I want know whether you treated it later or it was recovered by itself , thank you .
  • Seung-Jung Park 2003-07-23 Fig 7 clearly demonstrated near normal LCX ostium. Actually,we didn't treat the LCX ostium at the first procedure. There was some ostial compromise of the LCX immediately after after the procedure, which would be related with more vasoconstriction rather than the plaque displacement. Thank you.

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