Emergent Distal Vessel Re-Entry Technique for Iatrogenic Coronary Artery Dissection

Abstract

Complex iatrogenic coronary artery dissections are rare; however, when present, they may lead to increased patient morbidity if not promptly treated. We present a case of acute inferior wall myocardial infarction with complicating right coronary artery dissection, leading to complete vessel occlusion. Multiple strategies were used to enter the vessel true lumen at the dissection origin, but those efforts proved unsuccessful. Ultimately, a wire-based distal vessel re-entry technique was employed to achieve restoration of coronary flow.

Complex iatrogenic antegrade coronary artery dissections (IAD) encountered during percutaneous coronary intervention can have significant clinical consequences if not treated promptly. Corrective strategies start with appropriate wire selection and quickly progress to advanced wiring and imaging techniques to restore antegrade coronary flow, all in an effort to avoid emergent coronary artery bypass graft surgery or clinical deterioration of the patient. Herein, we present a case of iatrogenic antegrade coronary artery dissection and review the therapeutic choices in correcting this dilemma.

Case Presentation

A 56-year-old male with a history of coronary artery disease and prior drug-eluting stent placement to the left anterior descending artery (LAD) 2 years prior presented to the emergency department with sudden onset of dull chest discomfort, with nausea and diaphoresis. Electrocardiogram was consistent with acute inferior wall ST-elevation myocardial infarction (STEMI), with 2 mm ST-segment elevations in leads II, III, and AVF. He was given aspirin, ticagrelor, high-dose statin, and intravenous heparin, and taken emergently to the cardiac catheterization laboratory. Right radial artery access was obtained and a Judkins left (JL) 3.5 diagnostic catheter was used to perform left coronary angiography, revealing a widely patent mid left anterior descending (LAD) coronary artery stent with mild distal plaque and mild luminal irregularities in the left circumflex system. There were grade 1 left-to-right collaterals to the distal right coronary artery (Figure 1). A 6 French Judkins right (JR) 4.0 guide catheter was used for right coronary angiography, revealing a 100% proximal thrombotic occlusion of the right coronary artery (RCA) (Figure 2), which was easily crossed with an .014-inch Prowater wire (Abbott Vascular), restoring antegrade flow. The lesion was pre-dilated with a 2.5 mm x 12 mm semi-compliant balloon; however, subsequent post-inflation coronary contrast injection resulted in brief asystole, followed by sinus bradycardia (Video 1), which was treated with atropine and rapid insertion of a transvenous pacemaker through right common femoral vein access. During this brief period of time, the patient developed shortness of breath and a vigorous cough causing exaggerated body movement.

After stabilizing the patient’s conduction disturbance, fluoroscopy revealed both the coronary wire and guide catheter had completely disengaged from the RCA. Upon reengagement, angiogram revealed a type F antegrade coronary artery dissection with TIMI-0 flow (Figure 3). The Prowater wire was reinserted and attempts made to find the true lumen of the vessel, which were unsuccessful. A two-wire strategy was then attempted, with the Prowater wire within the false lumen, and a PT2 Moderate support wire (Boston Scientific) to attempt intraluminal crossing; however, this also proved futile. Intravascular ultrasound was then performed in an attempt to localize the origin of the dissection flap, but was ultimately unsuccessful. Next, 6 French right common femoral artery access was obtained and a JL 3.5 guide catheter used for contralateral injection of the left coronary circulation, in the hopes of visualizing the distal RCA via previously described left-to-right collaterals. However, the collaterals were not sufficient to guide antegrade wire advancement.

The antegrade RCA spiral dissection now extended to the distal RCA with continued TIMI-0 flow. The decision was made to attempt distal vessel re-entry. The PT2 Moderate support wire with a 1.5 mm x 12 mm over-the-wire (OTW) balloon was advanced in the dissection plane to the distal RCA (Figure 4). The wire was removed from the OTW balloon and negative suction performed with removal of blood from the dissection plane in order to reduce the size of the subintimal hematoma. A Confianza Pro 12 wire (Asahi Intecc), shaped with a 90-degree bend on its distal tip, was then used to successfully puncture through the distal dissection and re-enter the true lumen distally. The OTW balloon was advanced and distal vessel intraluminal position confirmed by contrast injection through the balloon (Figure 5, Video 2). A Prowater wire was placed through the OTW balloon into the distal right posterior descending artery and stent angioplasty performed with four drug-eluting stents (2.5 mm x 38 mm, 3.0 mm x 38 mm, 3.5 mm x 38 mm, and 3.5 mm x 12 mm Promus [Boston Scientific] stents). The stents were post-dilated with non-compliant balloons. Final angiogram demonstrated TIMI-III flow throughout the entire RCA system (Figure 6, Video 3). The patient was transferred to the medical intensive care unit and discharged 48 hours later in stable condition.

Discussion

Iatrogenic antegrade coronary artery dissection (IAD) is an unfortunate but well-known complication of coronary angiography and intervention, most commonly occurring in the setting of acute myocardial infarction. The clinical outcomes of IAD can vary greatly, ranging from additional stent placement with good long-term prognosis to prolonged ischemia leading to patient mortality.¹ While non flow-limiting coronary dissections are frequently encountered during routine balloon angioplasty, a type F coronary dissection, defined as dissection with complete distal vessel occlusion, is less common. Most reports of IAD focus on guide catheter or wire-induced precipitants; however, in our case, a type F dissection occurred once wire position was lost following balloon pre-dilation. Repositioning a wire in the true lumen in an extensive IAD can be challenging and may prove futile. This often results in the need for emergent coronary artery bypass graft surgery, making prompt management of this complication extremely important for the interventional cardiologist.¹

When dealing with complex coronary artery dissections, the first consideration should be to prevent further propagation by avoiding unnecessary contrast injections and finding a balance between guide catheter backup support and preventing deep coronary intubation.¹ A hydrophilic wire may offer a better chance of entering the true lumen, but decreased tactile feedback may increase the risk of further dissection. A double wire technique has been described, placing one wire in the false lumen as a marker, while attempting to cross the dissection with the second wire.² Intravascular ultrasound can also be utilized and may offer insight into the origin of dissection and wire position.³ A final strategy, as chosen in our case, is distal vessel reentry with either wire-based strategies or with a Stingray balloon (Boston Scientific). Similar to techniques used in chronic total occlusions, such as subintimal tracking and reentry (STAR)^4,5, once positioned adjacent to the distal vessel in the subintimal plane, a heavy-weighted tip wire with an aggressive bend can be used to enter the distal true lumen. Alternatively, a Stingray balloon can be positioned adjacent to the reentry point, and Stingray wire or Pilot 200 wire (Abbott Vascular) used to reenter the vessel. Due to the uncontrolled nature of IAD, it is important to avoid excessive contrast injection from the guide catheter, which can lead to further propagation and enlargement of the dissection plane, and formation of a subintimal hematoma. Negative aspiration through a support catheter at the distal dissection point may help decrease the size of a subintimal hematoma and improve the chance of successful vessel re-entry.

Conclusion

Prompt recognition and treatment of iatrogenic antegrade coronary dissection is paramount in achieving good outcomes. Herein, we present a case of acute inferior wall myocardial infarction with complicating iatrogenic coronary artery dissection requiring distal vessel re-entry technique to achieve successful revascularization. 

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Vincent Varghese, DO, FACC, FSCAI, Director, Interventional Cardiology Fellowship Program, Division of Interventional Cardiology and Endovascular Medicine, Deborah Heart and Lung Center, at varghesev@deborah.org

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