Dissection Type A – Case 1
- 56-year-old female who presented with chest pain (CCS Class IV) associated with dyspnea. Referred for staged PCI of OM1 and RI.
- HTN, HLD, DM, CAD s/p PCI, CVA, PE, Hypothyroidism, PUD, Asthma
- LVEF 60%
- Cardiac CTA: Severe 3-Vessel CAD.
- Prior Cardiac Catheterization: OM1 80-90% stenosis, RI 70-80% stenosis. S/p PCI of the LPL.
- Home Medications: Aspirin, Clopidogrel, Warfarin, Simvastatin, Metoprolol Tartrate, Lisinopril, Omeprazole, Insulin, Metformin, Albuterol, Fluticasone, Montelukast, Iron supplementation
- Adjunct Pharmacotherapy: Clopidogrel, Ticagrelor, Bivalirudin
Case Overview
- Underwent intervention of RI and OM1.
- Procedure was complicated by a guide catheter (VL 3.5/6 Fr) induced, non-flow-limiting Type A dissection of the LM.
- A stent was placed to treat the dissection; however, due to geographic miss another stent was required. This was followed by post dilatation of the stents, which successfully treated the dissection.
- Troponin-I was 0 ng/mL and CK-MB peaked at 2.1 ng/mL.
- Patient was discharged the next day without any sequelae.
Learning Objectives
- What is the likely explanation or reason why the complication occurred?
- Guide catheter-induced injury of an angiographically normal LM
- How could the complication have been prevented?
- Maintain guide catheter coaxiality, be cautious with manipulation of the guide catheter, and continuously monitor the position of the guide catheter throughout the procedure. This is extremely important when there is difficulty delivering equipment in tortuous and calcified lesions.
- Is there an alternate strategy that could have been used to manage the complication?
- Upfront use of a longer stent to cover the dissection flap.
- What are the important learning points?
- This is a type A dissection because there is a small linear streak with haziness, and no persistence of dye stasis.
- Always anticipate possible complications, especially when you have difficulty delivering equipment. It is reasonable to keep an additional balloon and stent on standby should a complication arise so they are readily available to use without delay.
- LM dissection is an emergency and a stent is almost always required to treat the dissection. LM dissection balloon tacking alone is insufficient because this will lead to a suboptimal result and a catastrophic event.
- If there is no residual LM disease, recommend to proceed to direct stent placement.
- If there is disease involving the LM, it is reasonable to first prep the lesion and tack the dissection with balloon inflation, and then place a stent.
- Remember to appropriately size the stent diameter and length to assure it adequately covers the entry and exit point of the dissection. We recommend routine LM intravascular imaging with IVUS, to determine the optimal stent length, diameter, and landing zones. Intravascular imaging would have been particularly helpful in this case, in differentiating the etiology of a radiolucency seen during angiography.
- In this case, the stent likely moved while deploying it due to patient’s respiration and/or rapid heart rate.
- To better manage patient’s respiration you should ask the patient to hold their breath prior to stent deployment.
- To better manage patient’s heart rate it is best to give IV adenosine 6 mg x one dose to control heart rate by inducing a transient, 6 to 8 second heart block prior to stent deployment. This is very important for placement of a stent involving an ostial lesion.