Bailout stenting for extensive dissection complicating direct infarct angioplasty

Abstract

Coronary artery dissection is a major cause of abrupt vessel closure, a complication seen in 2% to 10% of balloon angioplasty procedures. Stent implantation has been shown to be an effective treatment of arterial dissection after balloon angioplasty. 1 The stent serves as a metallic scaffold that seals the dissection flap against the arterial wall and maintains patency of the lumen. However, coronary stenting has been believed to be of questionable safety when dissection complicates direct infarct angioplasty because of the fear that placement of a metallic stent at the site of an acute infarction would result in an high rate of stent thrombosis. Two publications describe successful treatment of coronary dissections complicating direct infarct angioplasty with stents. 2, 3 The present report represents a case of extensive dissection and threatened vessel closure after direct infarct balloon angioplasty that was successfully treated by implantation of a Gianturco-Roubin Flex Stent (Cook, Bloomington, Ind.) Unlike the previously reported cases, in this case adjunct thrombolytic therapy was not used. This report adds to the emerging literature regarding bailout coronary stenting as a treatment for selected patients with abrupt or threatened closure after direct infarct angioplasty. A 48-year-old man was admitted to the hospital with an acute anterior myocardial infarction 6 hours after onset of pain. The admission electrocardiogram showed 8 to 10 mm of ST elevation in leads V2 through V6 and 3 mm of ST elevation in leads II, III, and AVF. Bradycardia and near syncope occurred en route to the cardiac catheterization laboratory, where a temporary pacemaker was placed. Cineangiography demonstrated total occlusion of the mid left anterior descending coronary artery and 70% obstruction of the mid right coronary artery. An 8F SL3.5 guide catheter (Medtronic, San Diego, Calif.) was engaged in the left main ostium, and a 0.014-inch Hi-Torque Floppy guide wire (Advanced Cardiovascular Systems, Temecula, Calif.) was advanced across the lesion. Inflation was performed with a 2.5 mm Freehand (Schneider, Minneapolis, Minn.) and then a 3.0 mm Flowtrack balloon (Advanced Cardio