Case 11: Angiographic filling defect due to stent edge dissection in ostial LM
Case Presentation
A 54-year-old female presented for an elective PCI for unstable angina to an outside hospital. Coronary angiography revealed an ostial LAD stenosis of 80% with positive iFR. During wiring of the LAD, manipulation of guide catheter resulted in a dissection of the LM propagating into the LAD, and LCx. Following LM dissection, the patient started having chest pain and dyspnea and went into shock. The patient was emergently intubated and cannulated with femoral Impella CP. Salvage PCI was performed with implanting four DESs into the LAD, LCx and LM, and the patient was transferred to our hospital for further shock management. Coronary angiogram showed angiographic haziness in the ostial LM, and further evaluation was performed using IVUS. IVUS images detected a proximal stent edge dissection in the LM with a dissection flap and possible hematoma formation outside the stent. In addition, IVUS showed LM stent underexpansion and malapposition in its proximal segment.
Manual IVUS Pre Pullback
Based on the angiography and IVUS, we performed pre-dilatation with a 5.0mm non-compliant balloon followed by deployment of a 4.0mm x 12mm DES in the ostial LM. Post-stent IVUS confirmed complete lesion coverage by the newly implanted stent with a minimal protrusion into the aorta. Stent expansion was satisfactory (MSA 11.0 mm²); no strut malapposition was detected by IVUS. Final angiogram had even distribution of contrast without any filling defect in the LM.
IVUS Post Pullback
In this case, IVUS allowed us to identify dissection and hematoma as potential causes of the haziness in the ostia LM and to confirm that the dissection entry was well covered after stent placement. We used an electronic scanning type IVUS for this emergency LM case due to its faster catheter preparation and no possibility for air bubble artifacts.
