Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
This is 80’s gentleman known history of diabetes mellitus and hypertension on medication. He complained of exertional chest pain from April 2015. Therefore, he was referred from his practitioner to our hospital. His general condition was good. His heart and lung sound was normal. He had no leg edema.
Relevant test results prior to catheterization
His ECG showed normal sinus rhythm, no ST change. His chest X-ray showed no cardiomegaly, no congestion. His heart echo showed no asynergy, no valvular disease. His coronary CT showed true bifurcation lesion between Obuse Marginal branch (OM) and Circumflex (Cx).
Relevant catheterization findings
He underwent for coronary angiogram (CAG) on May 2015. It showed that there were moderate stenosis in distal Right Coronary Artery (RCA), severe stenosis in proximal Left Antero descending artery (LAD). There were true bifurcation lesion between OM and Cx. We performed Percutaneous Coronary Interention (PCI) to this LAD lesion first. He was implanted Drug Eluting Stent 3.0(38) to proximal LAD at that time.
We performed PCI to Cx by the radial approach. We used EBU3.75 7F guiding catheter. We performed OFDI with a low molecular weight dextran for reduced the contrast dye, because his renal function was impaired less than eGFR60. It showed 1-1-1 true bifurcation lesion. We opened both lesions using 2.25 mm balloon. Then his OFDI showed the coronary artery dissection occurred at both arteries. Therefore,we planned the Culottes Stenting. We injected the contrast dye for stent position when the side branch stent deployment. At this time the contrast dye was pooled in the Cx below this bifurcation. We realized the coronary artery hematoma occurred in Cx. He had no symptom and no ECG change. Therefore, we deployed 2.5(18) DES to OM. Then, we implanted another 3.0(28) DES to the main branch for covered all the coronary artery hematoma. But the pooled contrast dye advanced to distal Cx. After this OFDI showed no hematoma in distal Cx until distal bifurcation site. Distal Cx was narrowed due to compressing from intramural coronary artery hematoma. Coronary artery dissection had seen out of the Cx stent until the stent overlapped site. Even after this event, he had no symptom, no ECG change. The final kissing balloon technique was done in these lesions. The final angiogram showed distal Cx was shrunken but the blood flow was good both arteries. Therefore,we could finish this procedure. One month after this procedure, the Cx coronary intramural hematoma was disappeared naturally and shrunk artery was improved.
We summarize this case. His Cx was dissected after ballooning. We performed OFDI after pre-dilatation with the low molecular weight dextran injection strongly. It may occur the coronary intramural hematoma was extended to distal Cx. We suspected this dissection had a lack of re-entry, that’s why it was extended distally. But we could bail-out this case without any special technique. This hematoma disappeared naturally 1 month period.
In conclusion, we should always consider about occurring the coronary intramural hematoma during OCT/OFDI guided PCI.