Author + information
- Yu Fukui1
Patient initials or identifier number
Relevant clinical history and physical exam
A 42-year-old Japanese male presented to the cardiology clinic, complaining of an episode of severe chest/back pain, which occurred five days prior to the visit. His initial electrocardiography (ECG) revealed no significant ST segment abnormalities. A few minutes later, he complained of severe chest pain and went into ventricular fibrillation, which treated with immediate defibrillation.
Relevant test results prior to catheterization
ECG changes at baseline(A) and with chest pain(B)
(A) Sinus rhythm, ST-T level within normal limit
(B) ST elevation in leads I, II, aVL, and V3–6, with reciprocal change in leads III, aVR, aVF, V1-2
Relevant catheterization findings
Coronary angiogram showed a dissection of the entire left coronary system with TIMI 1 flow. There were 90% stenosis in the proximal left anterior descending artery (LAD), a total occlusion of the mid LAD, 75%stenosis in the proximal left circumflex artery (LCx) and 99% stenosis in the distal LCx.
An intra-aortic balloon pump was placed and PCI of the left coronary artery was performed.
IVUS revealed the dissection of LAD, which extended into the left main trunk. With a narrower true lumen compressed by an extensive false lumen filled with a hematoma. Similar findings were confirmed in the LCx.
Initially, we performed a cutting balloon angioplasty of the LAD to create communications between the true and false lumens, aiming the reduction of the compression, and restore the distal coronary flow. A 3.0 mm cutting balloon was inflated to12 atm in the distal segment of the LAD. After ballooning, coronary flow remained TIMI II flow. Subsequently, we treated the left circumflex artery (LCx) with a 3.5 mm cutting balloon dilated to 12 atm. After ballooning, LCx flow was immediately restored to TIMI III flow.
Assuming that the 3.0mm balloon was not enough size to recanalize the LAD, we used 3.5 mm and 4.0 mm cutting balloon in the mid LAD respectively. As the result, the LAD flow further worsened to TIMI I. Since IVUS revealed the extension of the hematoma into the LMT, we considered that additional ballooning would not be effective and decided to implant a drug-eluting stent (DES) into an LAD-LMT segment. After the stenting, LAD flow was restored to TIMI III.
In the treatment of spontaneous coronary artery dissection, revascularization with a combination of the cutting balloon and the stent is effective. IVUS findings are crucial to determining the choice of appropriate device and techniques to restore the coronary flow.