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Proximal Stent Edge Dissection After LM PCI

A 71-year-old male, non-smoker with hypertension, hyperlipidemia and the history of chronic heart failure presented with angina pectoris. Coronary angiography revealed 3 vessel disease, and the patient and his family opted for PCI. The patient was referred to our hospital for a PCI of heavily calcified LM-LAD lesion (Figure 1, arrows).
First, we performed orbital atherectomy followed by pre-dilatation with non-compliant balloon and placement of two DES (3.25x28mm and 2.75x38mm) to LM-LAD. Post-stent angiography demonstrated TIMI 3 flow and detected a possible dissection at the proximal edge of 3.25×28 mm stent (Figure 2, arrow). OCT pullback confirmed the presence of proximal stent edge dissection and was used to quantify its circumferential and longitudinal extent (Figure 3).

Figure 3. Proximal stent edge dissection detected by OCT

OCT showed that although the dissection was within intima, the maximal arc was 95.7 degrees and longitudinal length was 3.4mm (Figure 3). The findings met the criteria for major dissection, therefore we considered an additional stent implantation (1,2). Another DES (3.0x23mm) was implanted into proximal LM covering the dissection with satisfactory angiographic result and no post-procedure complications (Figure 4).

  1. Raber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G, Group ESCSD. Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions. European heart journal 2018; 39:3281-3300.
  2. Ali ZA, Maehara A, Genereux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW, Investigators IIOP. Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial. Lancet 2016; 388:2618-2628.

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