Dear Left Main, Forgive Me!
Dr. Zhen-Vin LEE
University Malaya Medical Centre, Malaysia
A 54-year-old man has known history of diabetes mellitus, hypertension, dyslipidaemia and history of repeated PCI (to pRCA, dRCA, pLCx and OM2). Before the planned stage PCI to LAD lesion, he presented with sudden onset of central heavy chest pain. ECG revealed ST-segment elevation over the lateral leads.
Coronary angiography revealed normal left main coronary artery (LMCA), left anterior descending artery (LAD) had multiple segments of significant stenosis (80-90%) extending from ostium to mid LAD, left circumflex artery (LCx) had TIMI 0 flow (Movie 1, Movie 2) and stents in right coronary artery were patent (Movie 3). Percutaneous coronary intervention (PCI) was done via the right femoral approach. Thrombus aspiration was performed in the LCx. Multiple balloon dilatations were done and TIMI III flow was achieved (Movie 4).
Decision was then made to embark on bifurcation stenting with the Culotte technique as there were significant stenoses involving the ostium of the LAD and ostium of the LCx. Distal LMCA-LCx was first stented with a drug eluting stent (DES) followed by implantation of DES in distal LMCA-LAD, proximal LAD and mid LAD. Kissing balloon inflation (KBI) was then performed for the LMCA, LAD and LCx bifurcation (Figure 1). Right after KBI, patient had severe chest pain. It was noted that there was a dissection of the LMCA at the proximal stent edge with TIMI 0 flow (Movie 5). LMCA was bail-out stented with another DES. TIMI III flow was restored in the LAD, however, flow in the LCx was only TIMI I. Despite multiple balloon dilatations, there was recurrent no-reflow in LCx requiring intracoronary abciximab. TIMI II flow was achieved in LCx on final results (Movie 6).
On reviewing the angiogram, haziness was already noticed at proximal LM before KBI (Movie 7). Guiding catheter tip dissection or proximal stent edge dissection by post-dilating balloon were possible. KBI may further extend the dissection.
Post procedure, echocardiography revealed left ventricular ejection fraction of 25% with global hypokinesia, without significant valvular lesions or septal defects.
Patient’s subsequent stay was however, stormy, complicated by upper gastrointestinal bleed, acute kidney injury, hospital acquired infection and ultimately succumbed to illness 7 days after PCI.
Comments
This case illustrates the importance of co-axial of the guiding catheter to vessel during intervention. Guiding catheter tip dissection of LM or RCA is one of the common complications during coronary angiogram. Secondly, assessment of LMCA by image modality like intravascular ultrasound (IVUS) or optical coherent tomography (OCT) is important to provide accurate measurement of the size of the vessel and avoid oversizing of balloon for post-dilatation and causing dissection of vessel.