Perforation Type 2 Wire – Case 1
- 70-year-old male who presented with chest pain (CCS Class III).
Past Medical History
- HTN, HLD, CAD, DVT/PE (2009)
- LVEF 60%
- Cardiac CTA: Severe 3-Vessel CAD.
- Prior Cardiac Catheterization: Distal LM 60-70% stenosis, proximal LAD 70-80% stenosis, and proximal LCx 80-90% stenosis with severe calcification of the vessels.
- Home Medications: Home medications: Aspirin, Clopidogrel, Simvastatin, Ezetimibe, Fenofibrate, Atenolol, Amlodipine, Ranolazine
- Adjunct Pharmacotherapy: Clopidogrel, Ticagrelor, Bivalirudin
Pre-procedure EKG Heading
Right coronary artery (RCA) angiography
- 70-80% ostial stenosis in the RCA
- ulcerated subtotal lesion in the proximal to mid RCA
- Underwent OCT guided PCI of the distal LM bifurcation (distal LM MLA of 5.1 mm²).
- SKS technique was used to place a stent in the LM bifurcation.
- Procedure was complicated by a non-flow limiting, Type B dissection of the LM proximal to the newly placed stents.
- Two stents were placed in a ‘parallel, double barrel’ manner overlapping into the previously placed stents in the LM.
- Follow up angiography revealed, inadequate treatment of the dissection with incomplete coverage of the dissection flap.
- Patient was observed on the catheterization table and repeat angiography showed no change in the residual dissection.
- Post intervention OCT showed LM MLA 10.9 mm² with residual minor proximal edge dissection (residual dissection was < 2 mm in length). Therefore, further intervention was deferred.
- Troponin-I peaked at 0.4 ng/mL and CK-MB peaked at 2.6 ng/mL.
- Patient was discharged the next day without further sequelae.
- What is the likely explanation or reason why the complication occurred?
- High pressure post-dilatation of the proximal stent edge.
- How could the complication have been prevented?
- Optimize balloon position and assure it is not outside the proximal or distal stent edge prior to balloon inflation.
- Post-dilate the stent edges using a lower balloon inflation pressure.
- When performing SKS, KBI maximal pressure dilatation of the stent balloons is 12 atm simultaneously.
- When performing individual dilatation of the stents after SKS are placed, the maximal pressure to inflate the stent balloons is 16 atm.
- Consider using separate shorter NC balloons instead of the stent balloons after SKS were deployed.
- Is there an alternate strategy that could have been used to manage the complication?
- Consider an alternative stenting technique to treat the dissected segment such as reverse crush.
- Convert SKS into crush technique by crushing the LM-LCx stent with a balloon placed inside the LM-LAD stent, followed by recrossing of LCx and performing final KBI.
- What are the important learning points?
- This is a type B dissection because of the presence of a parallel tract linear defect seen during contrast injection.
- Maintaining wire position is extremely important, especially when dealing with complex interventions. Be cautious to avoid loss of wire position and possible wire entrapment.
- Guide catheter induced dissection should always be considered in the differential when there is a LM dissection.
- The larger the size of the guide catheter the higher the risk for guide catheter induced dissection. We used a large sized guide catheter (8 Fr) to accommodate the large size rota burr (2.15 mm).
- Optimize post dilatation technique.
- Use a noncompliant, short balloon for post-dilatation of a stent.
- Keep the balloon just inside the stent edge when performing post-dilatation of the proximal or distal stent edges.
- Use Stent Boost (Philips) or Stent Viz (GE) to assess the positioning of the NC balloon prior to inflation.
- Post intervention imaging with OCT was performed and the dissection length was < 2 mm. Conservative management is appropriate if the dissection length is < 2 mm and dissection is not propagating.
- The patient remained in the cardiac catheterization lab for 30 minutes. Repeat angiography was performed and dissection was stable; therefore, we opted for conservative management instead of performing further intervention.
- Note: SKS technique is now rarely being used.