Author + information
- Vipin Mughilassery Thomachan1
Patient initials or identifier number
Relevant clinical history and physical exam
A 43 year-old lady who is diabetic, hypertensive and dyslipidemic on treatmentpresented with Non ST elevation Acute Coronary Syndrome and AcceleratedSystemic Hypertension (Hypertensive urgency). BP was 180/133 mm of Hg and heartrate was 85 per minute. Otherwise, clinical examination was unremarkable.
Her ECG showed ST-T changes in Inferior andLateral leads and cardiac Troponins were high.
Relevant test results prior to catheterization
Echo showed normal left ventricular systolic function and no significant wall motion abnormalities.
Cardiac troponins were elevated.
Other blood tests were unremarkable.
Her ECG showed ST-T changes in Inferior and Lateral leads.
Relevant catheterization findings
The patient stabilized and was taken for coronary angiography on the next day after controlling blood pressure.
Coronary Angiography showed normal left coronaries distal right coronary artery showed tight diffuse stenosis involving ostial posterior descending artery.
Coronaryangiography was done through the right radial approach. Patient had significantradial spasm during the procedure. Coronary angiography, revealed normal leftcoronaries with tight diffuse lesion in distal right coronary artery withinvolvement of proximal posterior descending artery.
Right coronary ostium engaged with a 6F JR3.0 guiding catheter. But due to radial spasm, there was some difficulty incannulation and guiding was not stable. During the manipulation, the guidingcatheter abruptly got sucked into the RCA deep and it resulted in extensivedissection. Starting from proximal RCA as evidenced by persistent dye stainingand filling defect resulting in a severe limitation of forwarding flow,hemodynamic instability, ST elevation and severe chest pain. Her blood pressureat the beginning of procedure was 163/100 mm of hg which dropped to 80-90 mm ofhg range.
The patient sedated further includingmorphine to reduce chest pain and radial spasm. Then immediate intervention wasstarted through the same radial approach and using the same guidingcatheter with non-selective cannulation. Soft tipped BMW wire couldbe passed through true lumen and immediate stenting done starting from lesion wasstented after wiring PLV branch. Obtained good angiographic result, TIMI 3 flowand complete recovery of patient distal RCA up to RCA ostium using 3 DES.Patient's condition improved and subsequently PDA.
A43 years old lady who presented with non ST elevation myocardial infarction andaccelerated systemic hypertension had an Iatrogenic extensive dissection of RCAinduced by guiding catheter with immediate symptoms, ECG changes and
Haemodynamic compromise which wastackled immediately by wiring and stenting of the lesions. No retrogradeextension of dissection into aorta. Radial spasm is the most frequentcomplication of transradial procedures.
Iatrogenic coronary artery dissectionduring catheterization is a rare but life threatening event with a reportedincidence of less than 0.1%.In this case, unintentional deep intubationand uncontrolled blood pressure are leading cause for this dissection.