PCI-related compliations

PCI-related complications: Coronary artery dissection and thrombus formation

A 66-year-old hypertensive and diabetic male patient was admitted due to on-and-off chest pain which started 8 days ago. Troponin I was elevated. Transthoracic echocardiography showed global hypokinesia with a moderately depressed ejection fraction of 42%. He was managed as a case of non-ST elevation myocardial infarction. Coronary angiography was done using the right transradial approach without any complications. This revealed a sequential stenosis of 70% and 95% on the distal LCX before it terminates into an OM3 branch as seen in Figure 1. The LAD and RCA had luminal irregularities.

Percutaneous coronary intervention (PCI) of the LCX then performed. A 7F Voda Left 3.5 Mach 1 guiding catheter was used to cannulate the left coronary system. Sion Blue (Asahi Intecc, Japan) was used to wire the LCX. (MICROCATH) A 1.25 x 15 mm Sapphire (Orbus Neich) semi-compliant balloon was used to support the wiring of the distal segment. A 2.0 x 20 mm Mozec NC (Meril) non-compliant balloon was used to pre-dilate the distal segment. There was no reflow on contrast injection. A coronary artery dissection was considered by the operator. A Run-through Hypercoat (Terumo) was advanced parallel to the first wire and was distalized into the OM2 branch without any difficulty. The operators then started to pre-dilate the proximal to distal LCX but there continued to be no flow. A 2.5 x 16 mm Everolimus-eluting (Promus Premier) (Boston Scientific) stent was deployed proximally to restore flow.

Post-stenting, there was still no flow. Intravascular imaging was performed using a 3F Opticross (Boston Scientific) catheter which revealed both guide wires to be in the true lumen on the distal LCX (6). On gradual pullback, the wires were seen to be in the subintimal space with a large intramural hematoma compressing the true lumen (3-5). The deployed stent was seen to be under expanded and malapposed (2) a thrombus was visualized in the proximal segment (1).

The IVUS catheter was immediately removed. Thrombus aspiration was performed using a 6F Eliminate (Terumo) aspiration catheter and intracoronary Tirofiban injection (25 ug/kg) was given with restoration of flow. A 2.5 x 38 mm Everolimus-eluting (Promus Premier) (Boston Scientific) stents was deployed in the distal LCX, overlapping with the proximal stent. Post- dilation was performed using a 3.0 x 12 mm NC Quantum Apex (Boston Scientific) non-compliant balloon from the proximal to distal segment. Stent expansion and apposition were confirmed on IVUS. There was no significant residual stenosis with flow being restored.

Conflicts of interest:
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