Left main artery dissection with bail out stenting during percutaneous coronary intervention.

Abstract

Dear Editor We would like to report a case of left main dissection during angioplasty which we have successfully treated with bail out stenting. Left main coronary artery (LMCA) dissection is a rare complication during a catheter-based procedure. It is usually the result of injury related to manipulation of the guide catheter and coronary intervention for treatment of lesions in other vessels. A previous report described an incidence of LMCA dissection of <0.1%.1 If prompt action is not taken before development of hemodynamic deterioration, LMCA dissection may have fatal results. In this circumstance, stent implantation could be the fastest technique in achieving vessel patency and stabilizing hemodynamic status.2–5 We present a case of guide catheter-induced LMCA dissection that resulted in symptoms and ECG changes with subsequent successful stent implantation of Left main (LM) and then Left anterior descending artery (LAD). A 54-year-old male, hypertensive smoker presented with history of unstable angina in 2009 with chronic stable angina since January 2011, with positive stress test at 7 METS, with single vessel (Left Anterior Descending LAD) Coronary Artery Disease. Patient was posted for single vessel PCI (Fig. 1), The right femoral approach was used. During JL 3.5, 7 French guiding catheter manipulation, the patient complained of severe chest discomfort, and he had electrocardiographic changes (ST elevation in lead I, and reciprocal ST depression in II, III on monitor leads, followed by LBBB, bradycardia followed by recurrent Ventricle Fibrillation). Patient was resuscitated by multiple defibrillation with 360 J and support of temporary pacing and IABP. Simultaneous injection of contrast into the left coronary artery showed extensive dissection from the ostial Left main with proximal total occlusion (TIMI) grade 0 flow. Fig. 1 Pre-PTCA CAG. In this case, due to the critical condition of the patient with stormy clinical course, we decided to manage this complication with stenting of the dissected LMCA. We succeeded in passing 0.014 inch Fielder wire through LMCA into the true lumen of LAD (Fig. 2). Balloon inflation was done in LMCA with 2 × 10 mm PTCA semicompliant balloon (Sprinter–Medtronic) at 10 atm for 10 s. TIMI I flow was achieved in LMCA and proximal LAD. Another 0.014 inch Fielder PTCA wire was passed into the LCX and second balloon inflation done in LAD with same balloon at 10 atm for 10 s. Kissing balloon inflation done with semicompliant balloons one in LMCA into LAD and other into LCx. TIMI II flow achieved in LM to LAD and TIMI III flow in LCx with flap in LMCA to LAD. LM to LAD stented (Fig. 3) with 3 × 30 mm drug eluting stent (Yukon Choice) at 12 atm for 6 s. Another PTCA wire passed from LMCA to LCx through strut, previous wire in LCx removed and dilation given with 3 × 10 mm noncompliant ballon at 12 atm × 10 s. Check angio showed good result with TIMI III flow in LMCA, LCX and LAD (Fig. 4) with patient regained sinus rhythm and shifted to ICCU in hemodynamically stable condition with IABP support. Post procedure patient had stable course in ICCU with removal of IABP support in next 24 h. Fig. 2 LM dissection. Fig. 3 Stent across LM to LAD. Fig. 4 End result. Iatrogenic LMCA dissection results from mechanical injury to the arterial wall during guide catheter manipulation. The catheter type, stiffer and less manageable guide wires, unusual LMCA anatomy or location, operator experience, and presence of LMCA atherosclerosis have all been associated with an increased risk of dissection.6,7 A literature review by Cheng et al8 of 36 patients who underwent stenting of an iatrogenic LMCA dissection showed a favorable immediate outcome with achievement of procedural, angiographic success in 32 patients (88.9%). Four patients needed emergent CABG of whom 2 eventually died. This strategy, consisting of a primary attempt to stent with back-up CABG when needed, thus resulted in an overall survival rate of 94.4%. Prompt recognition of this potentially catastrophic complication and treatment with immediate stent deployment will result in good outcomes. When confronted with an iatrogenic LMCA dissection, prompt bail out stenting seems a reasonable and feasible first-choice option, with high immediate procedural success and acceptable long-term results.