Iatrogenic Acute Coronary Dissection During Coronary Angioplasty for In-Stent Restenosis: Role of Intravascular Ultrasound in Diagnosis and Treatment

ABSTRACT: We report on a case of coronary dissection resulting from a guidewire passing out of a stent during in-stent restenosis (ISR) treatment and a guidewire successfully negotiated into true lumen and an implanted stent under intravascular ultrasound guidance, resulting in optimal coronary blood flow.

J INVASIVE CARDIOL 2012;24(1):E1-E2

Key words: angioplasty, acute coronary dissection, intravascular ultrasound

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Coronary artery dissection following percutaneous transluminal coronary angioplasty (PTCA) occurs 20-40% angiographically and most small intimal dissections have a benign course.¹ In contrast, large complicated coronary artery dissections may cause acute coronary artery occlusion resulting in emergency coronary artery bypass graft, myocardial infarction, and even death.² We present a case of iatrogenic acute coronary dissection during coronary angioplasty for in-stent restenosis (ISR). Intravascular ultrasound (IVUS)-guided wiring successfully negotiated into the true lumen and an implanted stent resulted in optimal coronary blood flow.

Case Report

A 58-year-old man with diabetes and hypertension was admitted for angina and recurrent chest pain. He was admitted to another tertiary hospital 1 year prior for stable angina and had two Cypher stents (Cordis Corporation) implanted in the right coronary artery (RCA). No remarkable findings were observed on physical examination. His electrocardiogram, chest x-ray, and transthoracic echocardiogram were normal. Coronary angiography revealed a hazy lesion at mid-stent area suspicious of focal ISR or late stent thrombosis at the RCA (Figures 1A and 1B). The RCA was engaged with a JR 3.5 guiding catheter (Cordis Corporation) and a 0.014-inch Runthrough wire (Terumo Medical Corporation) crossed the ISR lesion with mild resistance. After ballooning with a 3.0 x 15 mm Rjujin balloon (Terumo Medical Corporation), coronary angiogram showed immediate dissection (Figure 1C), and chest pain developed. IVUS revealed that the guidewire was located out of the distorted stent with dissection (Figure 2). We negotiated another guidewire (Choice PT; Boston Scientific Corporation) several times in vain; however, with several trials, we were able to recanalize the true lumen on IVUS between the entry door of dissection and proper inner lumen. After confirming the second guidewire in the true lumen by IVUS (Figure 2), 3.0 x 23 mm and 2.5 x 33 mm Cypher stents were deployed consecutively. Final angiogram showed an excellent procedural result and no dissecting remnant at the ISR site (Figure 1D). The patient was discharged without complications.

Discussion

Coronary dissections occur frequently after balloon dilation of coronary atherosclerotic plaques and should be considered not only as a complication, but also as a part of the therapeutic mechanism of coronary angioplasty.⁴ However, plaque disruption with exposure of its prothrombotic milieu and concomitant intimal flaps may promote thrombosis and distal embolization or impair distal flow directly when large dissections are present.³

In a previous study,⁵ most cases of restenosis demonstrated a more benign pattern and were amenable to percutaneous treatment. Wiring in treatment of ISR is relatively simple because stent strut is a definite indicator of true lumen and the outside of the stent is full of plaque. However, our case of an ISR lesion showed no CTO lesion and no wire into false lumen was observed before ballooning. The cause of the guidewire passing throughout the stent was not clear, but this event might be attributable to late stent malapposition (LSM) and choice of a hydrophilic-coated guidewire. In the drug-eluting stent (DES) era, LSM occurrence was about 20%,⁶ compared with 4-5% when using a bare-metal stent.⁷ We speculate that coverage of part of the normal arterial wall with the stent may delay the healing process and result in LSM, which might cause easier entry of the hydrophilic-coated wire into the gap of stent apposition. Therefore, we recommend the use of a non-hydrophilic coated guidewire for treatment of ISR lesions in order to avoid false lumen canalization in the DES era.

Previous data show IVUS is effective for the visualization of aortocoronary dissection and guide fenestration interventional procedures in selected aortic dissections with sidebranch ischemia.⁸ Alfonso et al⁹ demonstrated the usefulness of IVUS to confirm diagnosis and to guide therapy in iatrogenic subtle coronary dissection. In addition, IVUS could provide precise diagnosis and guidance in recanalization of the true lumen in extensive coronary dissection, as shown in our case.

Conclusion

A more discrete effort with a non-hydrophilic coated guidewire would be needed to treat ISR lesions in order to avoid false lumen. IVUS could be a valuable option for use in evaluation of dissection and to guide the reparative stenting procedure to successful resolution of this complication.

References

1. Hermans WR, Foley DP, Rensing BJ, et al. Usefulness of quantitative and qualitative angiographic lesion morphology, and clinical characteristics in predicting major adverse cardiac events during and after native coronary balloon angioplasty. CARPORT and MERCATOR study groups. Am J Cardiol. 1993;72(1):14-20.
2. Bae JH, Kim KB, Kim KS, Kim YN. A case of aortocoronary dissection as a complication during a percutaneous transluminal coronary angioplasty. Int J Cardiol. 1998;66(3):237-240.
3. Biondi-Zoccai GG, Agostoni P, Sangiorgi GM, et al. Incidence, predictors, and outcomes of coronary dissections left untreated after drug-eluting stent implantation. Eur Heart J. 2006;27(5):540-546.
4. Costa MA, Kozuma K, Gaster AL, et al. Three dimensional intravascular ultrasonic assessment of the local mechanism of restenosis after balloon angioplasty. Heart. 2001;85(1):73-79.
5. Cosgrave J, Agostoni P, Ge L, et al. Clinical outcome following aleatory implantation of paclitaxel-eluting or sirolimus-eluting stents in complex coronary lesions. Am J Cardiol. 2005;96(12):1663-1668.
6. Shah VM, Mintz GS, Apple S, Weissman NJ. Background incidence of late malapposition after bare-metal stent implantation. Circulation. 2002;106(14):1753-1755.
7. Surruys PW, Degertekin M, Tanabe K, et al; for the RAVEL Study Group. Intravascular ultrasound findings in the multicenter, randomized, double blind RAVEL (RAndomized study with the sirolimus-eluting VElocity balloon-expandable stent in the treatment of patients with de novo native coronary artery Lesions) trial. Circulation. 2002;106(7):798-803.
8. Oda H, Hatada K, Sakai K, Takahasi K, Miida T, Higuma N. Aortocoronary dissection resolved by coronary stenting by intracoronary ultrasound. Circ J. 2004;68(4):389-391.
9. Alfonso F, Alvarez L, Almeria C. Iatrogenic subtle acute aortic dissection during coronary angioplasty for in-stent restenosis. Value of intravascular ultrasound. J Invasive Cardiol. 2004;16(9):511-513.

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From the ¹Department of Cardiology, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea, ²Department of Cardiology, Seoul Veterans Hospital, Seoul, Republic of Korea.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted April 12, 2011, provisional acceptance given May 16, 2011, final version accepted May 25, 2011.
Address for correspondence: Chang-Bum Park, MD, 134-727 East West Neo Medical Center, 149 Sangil-dong, Kangdong-gu, Seoul, Korea. Email: wwwpcb@hanmail.net