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Relevant clinical history and physical exam
A 57-year-old female with recent inferior posterior myocardial infarction, hypertension and hyperlipidemia presented to our hospital with intermittent effort chest discomfort for 2-3 months
Risk Factors: coronary artery disease, hypertension, hyperlipidemia, post menopause.
Relevant test results prior to catheterization
ECG Show: Normal sinus rhythm, T-wave inversion in the inferior leads and counterclockwise rotation of the QRS
UCG Show: Global EF: 45-50%, LV asynergy: mid septum hypokinesis, no significant valvular disease
Relevant catheterization findings
1) LMCA: Patent.
2) LAD: Luminal irregularity.
M/3: long-segment chronic total occlusion, receiving collateral flow from the conal branch of RCA.
3) LCX: Luminal irregularity. Co-dominant with RCA.
P/3∼D/3: s/p stent, without in-stent restenosis (ISR).
4) RCA: Luminal irregularity. Co-dominant with LCx.
M/3: 50% diffuse eccentric stenosis.
Conal branch: Big vessel diameter, giving collateral flow to LAD via a corkscrew epicardial collateral channel.
1. Perform LCA angiography with Guiding (6Fr EBU 3.5)-100cm;
2. Perform RCA angiography with Guiding (6Fr SAL-1 3.5)SH-100cm;
3. Perform retrograde approach using the epicardial collaterals from a conal branch with SION guidewire loaded in Corsair microcatheter. RG3 wire externalization was not possible because of relatively insufficient length of 150cm microcatheter to reach antegrade guide catheter after retrogradely traveling through standard-length guide catheter and very long epicardial collateral channel.
4. Perform antegrade wiring using the retrograde microcatheter as a marker with SION guidewire. The modified “rendezvous” technique was done successfully at the proximal LAD.
5. Implant Stent (BioMatrix 2.5*36mm) at the middle LAD.
6. The angiogram showed severe spiral dissection involving the proximal and middle RCA with compromised coronary flow.
7. IVUS-guided cutting balloon fenestration angioplasty was performed because of catheter-induced RCA dissection complicated by large intramural hematoma.
8. Implant Stents (BioMatrix 3.5*28mm + BioMatrix 3.0*36mm) at the proximal and middle RCA.
Thorough pre-procedural planning for revascularization of CTOs influences not only the complication rate but also the likelihood of successful percutaneous coronary intervention. Herein, we describe an iatrogenic RCA dissection followed by large intramural hematoma and compromised coronary flow during complex CTO revascularization of the LAD artery, which remains a rare, but still life-threatening condition. The adjunctive use of intravascular ultrasound may assist in the accurate diagnosis and treatment process. The patient was successfully treating with IVUS-guided fenestration using a cutting balloon, and two stents were implanted in the proximal and middle RCA respectively.