Bail-Out Stenting for Significant Left Main Coronary Artery Dissection During Guiding-Catheter Manipulation

- Operator : Seung-Jung Park

Bail-Out Stenting for Significant Left Main Coronary Artery Dissection During Guiding-Catheter Manipulation

- Operator: Seung-Jung Park, MD, PhD
Case Presentation
The patient was 61 year-old female. She had a history of unstable angina and underwent stenting at mid LAD, proximal RCA, and mid RCA 6 months ago. She was admitted for follow-up angiography due to chest discomfort.
Procedure
Follow-up coronary angiography was performed with a 7F Judkins catheter with 3.5 cm curve via radial approach. Engagement of guiding catheter was easily made. After initial contrast injection, contrast stasis and linear dissection was noted from left main to distal segment of LCX with TIMI 2 flow and blood pressure was dropped to 90/50mmHg (Figure 1, Figure 2). Thus we decided to treat this catastrophic complication with stent implantation. Dopamine was intravenously administrated and shock position was taken. Following coronary angiogram showed rapid progression of dissection. Therefore, LCX were wired with floppy guidewires and dissection in LCX was stented first with a Tsunami 3.0mmx30mm stent at 10 atm, after which the following angiography revealed restored flow of LCX without residual dissection (Figure 3). And then, LMCA was treated with a 4.0mmx13 mm Bx stent at 9 atm, confined to LMCA without protrusion into LCX or LAD. Final angiography showed well deployed stent in the LMCA and LCX without residual stenosis or dissection. Coronary flow was also restored to TIMI 3 flow (Figure 4, Figure 5). The hospital course was uneventful after stenting.

Comments

  • Bon-Kwon Koo 2003-08-15 I really appreciated this interesting case. I have two questions. 1. Why did you use the 7F catheter for diagonstic angiography via radial appraoch ? 2. What was the reason of her chest discomfort ? Although it was not clearly visualized, there seems to be an eccentric lesion at proximal LAD.
  • Seung-Jung Park 2003-08-16 1.During the follow up angiography, we would like to gather the data about the IVUS follow-up findings for the study if possible. And so, we have to use the 7F guiding catheter for the IVUS evaluation. 2.Initial symptom of her chest discomfort may not be related with cardiac origin. I don't want to touch the lesion on the proximal LAD in this emergency situation and it would be a part of diffuse disease. Actually, after the rescue procedure, we had perfomed the IVUS study, which clearly demonstrated preserved the ostium of LAD at that time. In any case, message from this case, 1. the patient should have some minimal disease on the left main and the other which may cause the dissection after simply guiding the cather on the main. We should be very careful to manuplate the cathether even in the routine angiogram for old aged patients. 2. We used the Tsunami stent without any difficulties for the recrossing the stented segment in the LCX. We prefer the Tsunami stent for the rescue procedure due to the merit of the lowest profile of this stent delivery system. Thank you.
  • Il-Soo Lee 2003-08-19
  • Debabrata Dash 2005-04-09 I appreciate you for the way you tackled this deadly complication.For diagnostic purposes one should try to use 4 or 5 F catheter.Well Tsunami is having low profile.But you could have used Drver or Vision stent as well.I do agree with you to treat LAD lesion later on if at all.

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