Diligence Diverts a Daymare

A 73-year-old woman with diabetes, hypertension, and non-ST elevation myocardial infarction underwent optical coherence tomography (OCT)-guided angioplasty for calcific stenosis of the mid-left anterior descending artery (LAD) and mid-segment of a tortuous obtuse marginal (OM) (Figure, A & B). Using a 6-French extra-backup 3.5 guide catheter, the left main artery (LM) was engaged, and the LAD and left circumflex (LCX) were wired. The LCX/OM was stented with a 2.75 x 33-mm drug-eluting stent (DES) after pre-dilatation under contrast-OCT pullback (Dragonfly Optis catheter; Abbott) (Figure, C). Stent tracking was slightly difficult due to tortuosity and calcium. 

During LAD lesion preparation, mild haziness was noted in the midshaft of the LM in cranial view. Left anterior oblique (LAO) caudal angulation showed a new lesion (Figure, D), which persisted even after intracoronary vasodilators. The patient complained of chest pain with electrocardiogram changes. Cautiously performed OCT pullback revealed a 12-mm medial dissection with evident entry and exit points. It was confined to the midshaft of the LM with an intramural hematoma (Figure, E-G; Video). Due to worsening angina, immediate bail-out LM stenting was done with a 4 x 15-mm DES. Subsequently, the LAD was stented with a 2.75 x 32-mm DES. Final angiographic result after optimization showed a well-apposed LM stent and OCT pullback revealed a sealed intramural hematoma (IMH)/dissection (Figure, H & I).

Iatrogenic dissection/IMH is an uncommon yet serious complication during coronary interventions. Haziness or appearance of a new lesion can be the initial or only finding on angiogram and can lead to serious consequences when not identified and treated promptly. Diligent attention to detail is needed, but angiography alone might be misleading in such scenarios. OCT offers better characterization and exclusion of other diagnoses. However, OCT should be carefully performed to prevent propagation of medial dissection during contrast injection, as it may cause luminal compromise and vessel closure. Bail-out stenting is a safe and quick therapeutic option for symptomatic iatrogenic dissection, especially those localized to the shaft of the LM. Catheter coaxiality and cautious manipulation is paramount to avoid such iatrogenic complications.

Affiliations and Disclosures

From the ¹Department of Cardiology SRM Medical College Hospital and Research Center, Chennai, Tamil Nadu, India; ²Department of Cardiology, Kauvery Heart Institute, Kauvery Hospital Radial Road, Chennai, Tamil Nadu, India.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Bharath Raj Kidambi, MD, DM, Department of Cardiology, Kauvery Heart Institute, No. 2/473 Radial Road, Kovilambakkam, Chennai-600 129, Tamil Nadu, India. Email: drbkid@gmail.com; X: @drbk67332258