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Relevant clinical history and physical exam
A 31-year-old man with acute anginal pain associated with nausea and dyspnea presented to our Emergency department 11 hours following the angina. His risk factors were hypertension, cigarette smoking and positive family history of IHD, as his father suffered MI at 50. His vital signs were stable during admission. Physical examination was unremarkable.
Relevant test results prior to catheterization
His ECG showed mild ST elevation at lead III, mild ST depression in V6, I and aVL, and biphasic T in V2-V5. His echocardiogram showed normal left ventricular function with no regional wall abnormality and mild left ventricular hypertrophy. His peak Troponin I was 8228.0 pg/ml.
Relevant catheterization findings
Coronary angiogram performed via right radial route. However, due to short ascending aorta there was difficulty to engage the coronary ostia. The LAD had CTO lesion with bridging collateral and retrograde filling from left Circumflex. The RCA had severe proximal lesion followed by mid-segment occlusion. Further on cranial projection proximal RCA dissection seen, which may have been spontaneous or catheter induced. Contrast staining at the dissected segment seen.
We used radial approach using a JR 3.5 6Fr catheter. It appeared now that the dissection has spread to the ostium of RCA. Gentle wiring attempted to select the true lumen. We could not wire the true lumen with BMW wire and Run through Floppy Hypercoat wire. We then changed to femoral approach, JR 4.0 6F was used. After several failed attempts (entry site of the dissection early at the ostium), we decided to sub selectively position the guide catheter and cannulate the RCA from outside with support from Sapphire II 1.0 X 10 mm balloon. Finally, we succeeded to cross the RCA and placed the wire distally through what perceived as a true lumen. IVUS performed and this confirmed the wire in the true lumen. A long segment of dissection involving the ostial and proximal RCA was seen.
Sequential dilation of the RCA with 2.0 mm balloon done. The angiogram showed good coronary flow to the distal segment, and the dissected segment showing entry level began at the ostium. Suddenly no-reflow phenomenon occurred. The flow reestablished with verapamil.
We then stented the RCA with 2 DES (Abluminus 2.25 x 40 mm and Combo 3.5 x 23 mm). However, another no-reflow phenomenon seen which required IC Verapamil, Adrenaline, and Abciximab. IVUS showed the presence of thrombus in the RCA. Repeated thrombo-aspiration and post-dilation of the stent with non-compliant balloon done. A final angiogram was excellent with TIMI 3 flow.
We then proceeded with PCI of the LAD CTO and the procedure completed with good result.
We presented a young man of 31-year-old with ACS and complex coronary lesions, involving extensive spontaneous dissection of ostial-proximal RCA and CTO of LAD. Crossing the dissected RCA was challenging, this made possible by positioning the catheter sub-selectively, and once the lesion crossed, IVUS confirmed the luminal position. The case was further complicated by no-reflow phenomena induced by clot requiring thromboaspiration and vasodilators.
The RCA intervention completed successfully and following this, complete revascularization successfully achieved by opening the LAD CTO. The final result was good and the patient recovered uneventfully.