Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 65 yearsold female non-diabetic, hypertensive women admitted with compressive chestpain for 8 hours. She diagnosed as a case of chronic stable angina 3 monthsback and was on anti-ischemic therapy. This time ECG showed RBBB ant ST segmentdepression in anterior leads and diagnosed as a case of NSTEMI based onpositive Trop I result.
Relevant test results prior to catheterization
ECG showed RBBB ant ST segment depression in anterior leads
Echo- Anterior wall hypokinesia, EF- 50%
Hb%- 10 mg/dl
RBS- 7 mmol/l
S. Creatinine- 1 mg/dl
Relevant catheterization findings
1) Normal left main coronary artery (Fig 1)
2) LAD: Proximal and mid segment 70-80% Narrowing (Fig 1)
3) LCX : (Fig 1)
4) RCA Dominant, normal (Fig 2)
PCI to LAD : 6F EBU 3.5 Guide Catheter, after Predilatation by 2.5 x 15 mm balloon a DES 2.75 x 48 mm tried to deployed across the lesion but failed. The guide catheter was deeply engaged into Left Main and try to deploy across the lesion but again fail. The patient develops severe chest pain with ST elevation. Check CAG showed severe dissection in to left main. At this point, we decided to fixed LAD lesion first and then left the Main dissection. The lesion was dilatation more by bigger size balloon and the DES 2.75 x 48 mm deployed in the proximal and mid segment of LAD with difficulty. Finally, another DES 3.5 x 22 mm deployed into left main to seal off the dissection with overlapping with the LAD Stent Post-dilatation. POT in LM with 4 mm NC balloon @ 18 atm.
The left main dissection is a devastating situation. Deep engagement of guide catheter should be avoided especially abnormal take off like our case. If it is happened be patient, steady and prompt. Adequate predilatation should be done especially for long stent implantation. Very minimal dye should be injection with minimum check short.