Author + information
- Tetsuro Kataoka1
Patient initials or identifier number
Relevant clinical history and physical exam
Case: 58 years old male
Coronary Risk Factors: Hypertension
Life History: Previous smoking
July 201 # transient chest pain was occurred onexertion
August 201# Chest pain and ECG change were sustained after stress test at local clinic
He was transported by ambulance
Physical Examination: BH 177 cm BW 79 kg BMI 25.2 BSA 1.96 m2
HR 86 bpm BP169/102 mmHg SpO2 98%
HS regular, no murmur RS vesicular, no rale
Jugular vein distension (-) Pretibial edema (-)
Relevant test results prior to catheterization
Electrocardiogram showed ST-segment elevation in lead aVR and ST-segment depression in inferior, anterior and lateral wall leads.
ChestX-ray showed neither cardiomegaly nor pulmonary congestion.
LV Wall Motion: Anteroseptal mid-apex severe hypokinesis, EF 68%
Aortic Stenosis (-) Mitral Regurgitation (-) Pericardial Effusion (-)
Relevant catheterization findings
The initial coronary angiography (CAG) showed total occlusion with thrombus in proximal left anterior descending artery (LAD). Right coronary artery supplied collateral flow to the distal LAD. The findings of intravascular ultrasound (IVUS) showed a quantity of thrombus diffusely remained in the proximal portion of LAD even after repetitive thrombus aspiration and pre-dilatation. The distal and proximal reference lumen diameter were 3.0 mm and 4.0 mm, respectively, and the lesion length was 38 mm.
A long Everolimus eluting stent (Promus Element 3.0/38 mm) deployed in proximal LAD. Subsequently, a series of post-dilatation was performed with a semi-compliant balloon (Sapphire II 3.5/20 mm) from the distal portion to the proximal portion of the stent, which would adhere the stent to the vessel wall to prevent from stent malapposition. The semi-compliant balloon was dilated to expand from 3.5 mm to 4.0 mm with 6 atm of inflation pressure in the distal portion, 10 atm in the middle portion, and 16 atm in the proximal portion of the stent. The findings of IVUS after post-dilation revealed longitudinal stent elongation toward left main trunk (LMT) across the orifice of a left circumflex coronary artery (LCx). The longitudinal length of 38 mm-stent was prolonged to 45 mm. Additionally, CAG showed residual thrombus derived from the culprit lesion shifting into the proximal site of LCx, then one more guide wire was attended to pass through the stent-struts for LCx, repetitive thrombus aspiration and balloon dilatation was performed to aspirate and fragment shifted thrombus. After the additional procedures, the final angiogram demonstrated acceptable results even if a small branch occluded by distal embolism. The door to balloon time was 82 minutes, the peak level of creatinine kinesis was 1349 IU/L.
We would like to report a case of longitudinal stent elongation during repetitive post-dilation with semi-compliant balloon resulted in the complication with residual thrombus shifting to LCx when performing emergent PCI.