Progression of dissection due to residual dissection after intracoronary stenting for spontaneous coronary dissection at bifurcation site of LAD and diagonal artery

Abstract

A 34-year old male patient visited our hospital due to severe chest pain. Initial ECG showed ST elevation at precordial leads and all cardiac enzymes were markedly elevated. Coronary angiography showed a long, longitudinal coronary dissection with dissected flap extending from the proximal LAD to the mid segment of the vessel and proximal diagonal artery. IVUS showed dissected flap and false lumen communicating with true lumen from proximal to mid-LAD. We implanted two paclitaxel-eluting stents using crushing technique at bifurcation lesion and overlapped another paclitaxel-eluting stent at proximal LAD for full coverage of dissection. Final angiography showed good distal flow. However, despite of maximal pressure of post stent ballooning, a residual dissection was noted at proximal LAD. IVUS examination also showed encircling gap that was noted between stent and vessel wall at proximal LAD stent area. Because distal flow was good and there was no ischemic symptom and sign, the patient was discharged. Six months later from index procedure, routine follow-up angiography and IVUS examination were performed and revealed more progressed previous residual coronary dissection at proximal LAD which was extended to bifurcation site. Our case showed, although intracoronary stenting might be an attractive approach by closure of the inlet and the false lumen, complete resolution of dissection by stenting is very important for long-term prognosis.