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Relevant clinical history and physical exam
A 54-year-old nondiabetic, normotensive, dyslipidemic with positive family history for IHD was admitted in an emergency with the complaints of severe central chest pain for last 6 hours. ECG showed acute STEMI (inferior with RV infarction).The patient was otherwise hemodynamically stable with bedside echo which revealed LVEF ∼50%. The was sent for pPCI in cath lab within 40 minutes of presentation.
Relevant test results prior to catheterization.
Relevant catheterization findings
CAG was done through transradial approach. Left sided engagement was impossible by TIG diagnostic catheter. So, 5FXB 3.5 guide catheter was taken to engage left system which is a regular and effective practice in our cath lab. CAG revealed severely diseased RCA. LMS showed catheter-induced dissection. LAD and LCx were otherwise disease free. OM branch has the moderate disease.
The patient had severe chest pain. But still, the hemodynamics was not compromised. Leaving pPCI to RCA, we have to jump for fixing the dissection of LMS. Using 6 F JL 4.0 guide catheter, LAD and LCx were wired by two Sion Blue guide wire. Pre-dilatation was done in LMS by 2.5 x 10 mm Saphire NC balloon. Then jailing the wire in LCx, shaft and distal LMS was stented by a COMBO (medicated EPC coated) stent 4.0 x 15 mm at maximum 16 ATM for 20 sec. Post dilatation was done by 4.5 x 10 mm Sapphire NC balloon at maximum 20 ATM.
Then target lesion in RCA was wired by Sion Blue wire and directly stented by another Combo stent 3.5 x 23 mm at maximum 18 ATM. Distal TIMI III flow was achieved.
Iatrogenic LMS dissection while doing diagnostic angiography is not a common phenomena. Especially at the setting of STEMI, non-culprit vessel dissection during angiography is a monstrous complication. Meticulous screening is necessary to find out the dissection. XB 3.5 5 F guide catheter is a pretty useful tool for an abnormally originated left system to be engaged according to our experience as our center is a high volume center with 99.5% of the procedures are done by the transradial approach.
While confronting this sort of grave situation, there is no need to switch to vascular access.