Guide catheter tip-induced type-II aortocoronary dissection bailed out by stenting the left main coronary artery

Dibyasundar Mahanta; Jogendra Singh; Rudra Pratap Mahapatra; Ramachandra Barik

doi:10.4103/jicc.jicc_33_21

CASE REPORT

Year : 2022 | Volume : 12 | Issue : 3 | Page : 133-135

Guide catheter tip-induced type-II aortocoronary dissection bailed out by stenting the left main coronary artery

Dibyasundar Mahanta¹, Jogendra Singh¹, Rudra Pratap Mahapatra², Ramachandra Barik¹
¹ Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
² Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission	30-May-2021
Date of Decision	28-Jul-2021
Date of Acceptance	02-Aug-2021
Date of Web Publication	14-Sep-2022

Correspondence Address:
Dr. Ramachandra Barik
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicc.jicc_33_21

Abstract

Left main coronary artery dissection induced by the tip of the guide catheter (Razor blade effect) with or without extension into the adjacent aortic wall can result in no flow. It is being a life threatening, complication and must be time timely detected and treated by stenting or surgery. A 59-year-old male patient presented with crescendo angina having a history of stenting to left anterior descending coronary artery (LAD) using 3 mm × 23 mm drug-eluting stent 5 years back. Coronary angiogram revealed 100% instent re-stenosis of the LAD. Left circumflex (LCX) coronary artery had proximal chronic total occlusion with J-CTO score of ≥2.The dominant right coronary artery was normal. LMCA dissection was noticed like an invisible dragon from nowhere after stenting of the proximal LCX followed by abrupt retrograde extension into aorta, resulting in no flow in the left coronary artery. The true lumen of LMCA was re-wired, and timely bailout stenting from LMCA to LCX was performed.

Keywords: Aortic dissection, bail-out stenting, catheter tip induced, crescendo angina, instent restenosis, left main dissection

How to cite this article:
Mahanta D, Singh J, Mahapatra RP, Barik R. Guide catheter tip-induced type-II aortocoronary dissection bailed out by stenting the left main coronary artery. J Indian coll cardiol 2022;12:133-5

How to cite this URL:
Mahanta D, Singh J, Mahapatra RP, Barik R. Guide catheter tip-induced type-II aortocoronary dissection bailed out by stenting the left main coronary artery. J Indian coll cardiol [serial online] 2022 [cited 2023 Feb 8];12:133-5. Available from: https://www.joicc.org/text.asp?2022/12/3/133/356062

Introduction

Guide catheter tip-induced dissection of the left main coronary artery (LMCA) is a rare, but timely bailout is necessary to save life.^[1],[2],[3] This case report describes a scenario where a guiding catheter tip-induced aorto-coronary dissection was timely bailed out by LMCA stenting, and aortic dissection adjacent to the ostium of the LMCA was managed conservatively with close follow-up.^[1]

Case Report

A 59-year-old male presented with worsening effort angina of Canadian Cardiovascular Society grade II to grade III over the last 5 months. He was nondiabetic and hypertensive. He had undergone stenting to LAD using 3 mm × 20 mm DES 5 years back. A 12-lead electrocardiogram [Figure 1]a showed Q in V1–V5, and two-dimensional (2D) echo showed the evidence of old AWMI with HFrEF [Figure 1]b and [Figure 1]c. Coronary angiogram from the right radial access showed 100% ISR of LAD stent [[Figure 2]a, Video 1], proximal LCX had CTO with J-CTO score of 2 [Figure 2]a, and right coronary artery was dominant and normal. Heart team was consulted, but the patient only agreed for angioplasty. Therefore, percutaneous coronary intervention and stenting to LAD and LCX were decided. As LAD ISR crossing was not possible using Fielder XT-A guide wire, only proximal LCX stenting was planned. A serial dilatation of the LCX lesion resulted in establishing TIMI-III follow [[Figure 2]b, Video 2]. It was followed by successful stenting of LCX. However, immediately after LCX proximal part was stented, the guide catheter tip-induced dissection was noticed from nowhere like an invisible dragon in the LMCA ostium [Figure 3]a, which extended into proximal part of the LCX and adjacent aortic wall (Type-II) [Figure 3]b in no time resulting in no flow in the left coronary artery [Video 3 and 4]. Repeated dilatation of the LCX could not re-establish blood flow in the LCX. His systolic blood pressure reduced to 80 mmHg from 130 mmHg. The patient supported with volume and inotrope. One episode of ventricular tachycardia was reverted by defibrillation. The wiring of the true lumen of the LMCA was difficult because the guide catheter was entering into the false lumen, and the guide wire distally was reaching up to the proximal part of the LCX stent. Then, the true lumen of LMCA was tried to cross in a bit a lower down position of tip of the guide catheter. We could succeed in entering true lumen of LMCA and LCX. A second DES was implanted from the ostium of the LMCA into the proximal part of LCX re-establishing TIMI III flow [[Figure 4], Video 5]. The patient became chest pain-free, and his hemodynamic status improved. The progress of aortic dissection was followed carefully under echocardiographic guidance and managed conservatively. This patient was discharged on the 4^th day, was reviewed at the end of 1^st month, and was asymptomatic on ticagrelor, aspirin, statin, and heart failure medication including ARNI. At the end of 6 weeks, the ejection fraction improved to 39% and there was no apparent dissection in 2D echo. A regular follow-up with 2D echo is consistent with the complete healing of the aortic dissection and almost normalized aorta during the last 18 months.

Figure 1: (a) Sinus rhythm Q in V1–V5 and poor R wave progression; (b and c) showing thin and hypokinetic distal IVS and anterior wall, mild mitral regurgitation, and ejection fraction of 35%

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Figure 2: (a) Coronary angiogram via right radial approach showing left anterior descending stent has 100% instent restenosis (yellow arrow), nondominant left circumflex had 100% occlusion with distal formation by bridging collaterals (red arrow). (b) Serial balloon dilatation of chronic total occlusion in the proximal part of the left circumflex showing TIMI-III flow

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Figure 3: (a) A Promus Element Plus, 2.75 mm × 20 mm was deployed in the proximal left circumflex followed by postdilatation with TIMI-III flow in the left circumflex. However, we noticed aorto-left main ostial dissection extending into ascending and up to the ostium of the left circumflex resulting due to razor blade effect (injury caused by the tip of the left guide catheter). There was no flow into left main. The dissection in the left main coronary artery ostium is obvious and marked by red arrow; (b) a 4 mm × 20 mm Orsiro stent was deployed from left main coronary artery ostium to left circumflex. The dissection in the ascending aorta is marked by the yellow arrow

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Figure 4: Final angiographic sort after left main to left circumflex stenting showing complete coverage of the dissection part and restoration of left main coronary artery lumen and TIMI-III flow in the left circumflex

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Discussion

The incidence of left main dissection during coronary angiogram or angioplasty is <0.1%.^[4],[5],[6] It is rare to come across LMCA dissection with retrograde extension into the ascending aorta and the aortic root.^[1],[4],[7] There are several technical factors that increase the risk of left main dissection including the improper guide catheter alignment , use of stiff-tipped or hydrophilic-tipped guide wires to cross tightly narrowed or total occlusion , deeply intubated catheter, large-bore catheter, Amplatzer guide, deep respiration, high-pressure contrast injection, and careless removal of deflated large diameter stent balloon or the post-dilatation balloon.^[8],[9] In our case, coronary dissection was type-F (dissection resulting in no distal flow)^[10] and the retrograde aortic dissection was Class II (dissections involve the corresponding aortic sinus and extend <40 mm into the aorta) which was managed by closed watch and conservative approach.^[4] A bailout stenting for iatrogenic LMCA dissection is associated with 92.6% survival and only a few need CABG.^[11] The optimal control of blood pressure and use of a β-blocker is useful in aorto-LMCA dissection, and conservative approach is successful in about 50% of the patients with retrograde extension of the dissection in the ascending aorta.^[12] In our case, a contrast-enhanced computed tomography of the thoracic aorta would have been an academic interest, but we have not done because the follow-up echo did not show any significant changes in the aortic root or ascending aorta and the left ventricular ejection fraction of this patient was <40%.

Conclusion

In the cases of catheter tip-induced aortocoronary dissection, LMCA must be stented as soon as possible as bailout procedure to save life and aortic dissection can be managed conservatively if the aortic dissection is <4 cm into the adjacent aorta, but the associated aortic dissection must be watched carefully in each visit which usually heals with time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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