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Patient initials or identifier number
Relevant clinical history and physical exam
A 60 year-old man made an appointment at our institution due to progressive chest pain during exertion in the recent months. His risk factors were current smoker and dyslipidemia. On physical examination, his blood pressure was 137/82 mmHg, heart rate was 73 beats/min and respiratory rate was 17/min. The heart and breath sounds were normal.
Relevant test results prior to catheterization
The coronary computed tomography revealed the 90% stenosis of proximal left anterior descending (LAD) and 50% stenosis of proximal right coronary artery disease (RCA). There is reversible perfusion deficit in the septal and lateral wall in the thallium heart scan. The electrocardiogram (ECG) was normal sinus rhythm. Chest X-ray showed heart size in normal range.
Relevant catheterization findings
Sequential coronary arteriogram from right to left coronary arteries revealed RCA –P 40% stenosis, patent left main coronary artery (LMCA), 90% stenosis of LAD-P to –M and LCX-D 30% stenosis. However, right after the first injection at the left coronary orifice, patient complained severe chest pain and precordial ECG showed ST elevation. Diffuse dissection with contrast stained and sluggish flow extended from LMCA to both LAD and LCX disclosed.
An EBU 3.5/6 guidingcatheter engaged at LMCA immediately. A Sion GW delivered to LAD-D, two FielderFC GW, one was delivered to LCX-OM1 and the other delivered to LCX-D. A Tazuna3.0 x 20 mm BC inflated at LAD-M with pressure up to 6 barr to open thecritical stenosis of LAD-P. Intravascular ultrasound (IVUS) revealed dissectionextended from LMCA to LAD and LCX and the true lumen of LMCA compressed byintramural hematoma. The hematoma at LM to LAD-M was fenestrated by a 3.75 x 10mm cutting balloon with pressure up to 4 barr, and another 3.0 x 10 mm cuttingballoon with pressure up to 4 barr applied at LCX-P to -M. A Xience Xpedition3.25 x 28 mm DES deployed at LCX-Os to M with T-stenting and small protrusiontechnique. Another Orsiro 4.0 x 40 mm DES deployed at LM-Os to LAD-M sequentially.Kissing balloon technique (KBT) applied with a Tazuna 3.0 x 20 mm BC at LM toLCX-P and a Sprinter Legend 3.0 x 20 mm at LMCA to LAD-P with pressure up to 9and 10 barr, respectively. The post-stenting IVUS disclosed fair resolution ofintramural hematoma and well apposition of stent. The final angiography was acceptablewith TIMI III flow in LMCA, LAD and LCX territories.
Iatrogenic dissection of the LMCA is a rare but potentially devastating complication of coronary catheterization (0.1-0.2%). Endovascular revascularization such as bailout stenting or urgent coronary artery bypass grafting (CABG) were two rescue procedures and delineated no difference in clinical outcome of in-hospital and 5-year follow-up. In our case, we used cutting balloon to create fenestration to decompress intramural hematoma followed by bailout stenting over LM to LAD and LCX, and finished with kissing balloon technique. After the angioplasty procedure, patient was angina-free and discharged 4 days later and followed up at the Outpatient Clinic.