Lmca dissection

Catheter InducedLeftmain Dissection

Dr. Dinh Huynh LinhNNational Heart Centre Singapore

Vietnam National Heart Institute

Dr. Jack Tan Wei ChiehNational Heart Centre SingaporeNational Heart Centre Singapore

http://www.nhcs.com.sg/DoctorProfile/Pages/view.aspx?_id=3199ea3e-1a84-4ed8-be2e-34c4aff201dc&name=Yeo+Khung+Keong&institution=National+Heart+Centre+Singapore





• 59 year old gentleman

• Persistent AF, with history of lower limb artery thrombus. On warfarin

• Thorax CT: bronchus stricture + mediastinal lymphadenophathy. Will need lung biopsy

• NSTEMI in November 2012

• MPI: inferior-lateral ischaemia.

• Angiogram: DVD (RCA + LCx)

• PCI in RCA CTO. EF improved, from 24 to 39%

• Elective admission for staged PCI in the LCx

Case presentation

RCA CTO intervention on Nov 2, 2012Genous 3.5 x 33 + MultiLink 3.0 x 38

Post-procedure

QuickTime™ and aH.264 decompressor

are needed to see this picture.

Pre-procedure



Supposed to be a straightforward 15-minute PCI case

•Type B1 lesion

•Radial approach

•6 French sheath

•EBU 3.75 6F guide

Scheduled PCI to mid-LCx



Avanta Fluid Injection System

•Volume: 6 mL

•Rate: 5 mL/s

•1000 PSI

First injection


are needed to see this picture. Suspected acute LMCA spiral dissection, extending into LAD and LCx

• Dissection?

• Air embolism?

Catheter induced spiral dissection of LMCA

Clinical course



• Acute LMCA dissection. TIMI 1 flow in both LAD and LCx

• Retrograde dissection to the coronary sinus

• Pt had chest pain, hypotension, VT, then VF. Multiple defibrillation performed

• Heparin had already been given (5500 IU) after catheter engagement

1. CABG

2. PCI

3. Medical therapy

Q1: What to do next?



1.No mechanical circulatory support

2.Mechanical circulatory support: IABP

3.Mechanical circulatory support : ECMO

4.Other opinion

Q2: What to do next?



1.To stent backward or forward?

2.6F or 7F guiding catheter?

PCI: open question?



1.Hydrophillic guidewire

2.Hydrophobic guidewire

Q4: PCI: which guidewire?



• The surgical team and ECMO team were activated

• Senior consultant was called for help

• Strategy: Stent the LMCA, LAD, LCx

• RFA puncture

• JL 3.5 6F guide

• Fielder 0.014” to distal LAD

Management

The LMCA’s ostium was covered





Genous 3.5 x 33 stent in LMCA



Restoration of LAD and LCx flow after LMCA stenting and post-dilatation







Stents implantation in LAD and LCx

Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)Coroflex Blue 3.0 x 16 mm in mid LCx

Coroflex Blue 3.0 x 28 mm in ostial LCx (TAP technique)



Final kissing balloon inflation









Final results

• Dissection into the left coronary cusp. The right cusp was not involved

• BP 151/64/86, HR 55 bpm, SpO2 97%

• Protamin given to neutralize heparin

• IABP was not inserted due to aortic dissection and stable condition





Proximal ascending aorta intramural hematoma, from the LMCA, extending till the sinotubular junction

Thorax CT Angiography

LMCA

• Patient was clinically stable. No chest pain

• ECHO: no pericardial effusion, no LV thrombus

• No EKG changes

• No postprocedural cardiac enzyme elevation

• Patient was discharged well 4 days later, on aspirin 100 mg and clopidogrel 75 mg

Post-procedural course

12.2012 1.2013

CTA 1 month laterComplete healing of the ascending aorta

• Follow-up CT: The intramural hematoma in the posterior wall of the proximal ascending aorta shows complete resolution

• Lung cancer was excluded

• Restart warfarin

• Life long aspirin. 2 months of clopidogrel

• Pt recovered uneventfully. No recurrence of angina

Clinical follow-up

• Catheter induced LMCA dissection:

• 0.008 to 0.02% of diagnostic catheterizations

• 0.06 to 0.07% of PCI

• Ostial LMCA dissection is rarer than RCA dissection

• Risk factors: LMCA disease, Amplatz usage, acute MI, catheter manipulation, hard contrast injection

• Urgent revascularization is mandated

• Retrograde dissection involving the coronary cusp or extending up the aortic wall < 40 mm: conservative treatment

Literature review

Boyle AJ et al. Catheter-induced coronary artery dissection: risk factors, prevention and management. J Invasive Cardiol. 2006 Oct;18(10):500-3

http://www.ncbi.nlm.nih.gov/pubmed?term=Boyle%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=17015916

http://www.ncbi.nlm.nih.gov/pubmed?term=Catheter-Induced%20Coronary%20Artery%20Dissection%3A%20Risk%20Factors%2C%20Prevention%20and%20Management#

• Guiding catheter can be dangerous, especially if not co-axially engaged

• Vigorous contrast injection can be dangerous

• PCI is a life-saving approach for acute LMCA dissection

• Complete seal-off of the entry site, as well as the LMCA’s origin, is important to prevent the further extension of the dissection

• Limited dissection to the aorta can be treated conservatively, without any surgical intervention

• Always call for help

What I have learnt

Thank you!

Catheter InducedLeftmain Dissection

Dr. Dinh Huynh LinhNNational Heart Centre Singapore

Vietnam National Heart Institute

Dr. Jack Tan Wei ChiehDr. Jack Tan Wei ChiehNational Heart Centre SingaporeNational Heart Centre Singapore




• 59 year old male

• Persistent AF, on warfarin. History of lower limb artery thrombus, treated with thrombolysis

• Mediastinal and hilar lymphadenophathy

• NSTEMI in November 2012

• MPI: inferior-lateral ischaemia. EF=24%.

• Angiogram: double vessel disease

• PCI in RCA CTO

• Elective admission for checking prior stents in RCA and PCI in the LCx

Case presentation

The LMCA was stented (Genous 3.5 x 33 mm at 16 atm)Post-dilate the LMCA with Hiryu 3.5 x 15 mm NC balloon







Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)



RCA CTO intervention on Nov 2, 2012Genous 3.5 x 33 + MultiLink 3.0 x 38

Post-procedure



Pre-procedure



Angiogram on Dec 11, 2012

December 11November 2



• 59 year old gentleman.

• Persistent AF, on warfarin

• Thorax CT: suspected lung maglinancy. Will need lung biopsy

• NSTEMI in November 2012 with inferior-lateral ischemia on MPI

• Angiogram: DVD (RCA + LCx)

• PCI in RCA. EF improved from 24% to 39%

• Elective admission for staged PCI in the LCx

IVUS

Education

Lmca dissection