CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 4, May 2012
e6
AFRICA
Case Report
Successful stenting of catheter-induced unprotected
left main coronary artery dissection
G ERTAŞ, E URAL, WJ VAN DER GİESSEN
Abstract
Catheter-induced left main coronary artery (LMCA) dissec-
tion is a dramatic, although uncommon complication of diag-
nostic coronary angiography and requires prompt treatment.
We describe a case of iatrogenic occlusive dissection of the
LMCA during coronary angiography, treated by subsequent
percutaneous recanalisation.
Keywords:
LMCA, coronary artery dissection, stent
Submitted 30/12/09, accepted 26/6/11
Cardiovasc J Afr
2012;
23
: e6–e7
DOI: 10.5830/CVJA-2011-033
Case report
A 58-year-old female with a 10-year history of hypertension was
admitted with stable angina pectoris (Canadian Cardiovascular
Society class II). On admission, the patient’s arterial pressure
was 130/70 mmHg and her heart rate was 84 beats/min. The ECG
showed negative T waves in leads V4–6. An exercise treadmill
test was inconclusive. Transthoracic echocardiography revealed
global left ventricular hypokinesia with a left ventricular ejection
fraction of 40%.
She underwent diagnostic coronary angiography. Left coronary
angiography revealed a normal arterial tree (Fig. 1A). After the
first two contrast injections, the patient experienced severe chest
pain and became hypotensive. The electrocardiogram showed
ST-segment elevation. Coronary injection revealed there was no
contrast medium passing beyond the distal left main coronary
artery (LMCA) (Fig. 1B). Catheter-induced LMCA dissection
was concluded and because of the haemodynamic deterioration,
urgent percutaneous coronary intervention was performed.
After a loading dose of 600 mg clopidogrel and 300 mg of
aspirin, an intra-aortic balloon pump was inserted from the left
common femoral artery for haemodynamic support during the
procedure. A floppy coronary guide wire could not be advanced
to the distal left anterior descending (LAD) artery, so with the
wire in the first septal branch, a bare-metal stent (4
×
24-mm
Liberté) was implanted in the LMCA towards the LAD (Fig.
2A). Circumflex coronary arterial flow was restored but because
of a spiral dissection, there was no flow in the distal LAD (Fig.
2B).
Subsequent attempts to advance the wire were unsuccessful.
Leaving the first wire in the mid-LAD, a second floppy wire
could easily be advanced to the distal vessel. A second bare-
metal stent (3
×
32-mm Liberté) was implanted, overlapping with
the first stent. TIMI 3 flow was obtained (Fig. 2C).
Post-procedure troponin levels remained negative and the
echocardiogram revealed no change in wall-motion abnormality
compared to baseline. After an uneventful period, the patient
was discharged on post-procedural day nine. She remained
asymptomatic during one year of follow up.
Department of Cardiology, Faculty of Medicine, Bezmialem
Vakif University, Istanbul, Turkey
G ERTAŞ, MD,
Department of Cardiology, Medical Faculty, and
Interventional Cardiology Research and Application Unit,
Kocaeli University, Kocaeli, Turkey
E URAL, MD
Department of Cardiology, Thoraxcentre, Erasmus MC,
Rotterdam, and Interuniversity Cardiology Institute of the
Netherlands, ICIN-KNAW, Utrecht, the Netherlands
WJ VAN DER GİESSEN, MD, PhD
A
B
Fig. 1. (A) Left coronary angiography revealed a normal
arterial tree. (B) Coronary injection revealed there was no
contrast medium passing beyond the distal LMCA.
A
B
C
Fig. 2. (A) A bare-metal stent from the LMCA to the LAD
was implanted. (B) After stent placement, flow to the
circumflex artery was restored, but there was no flow in
the distal LAD because of the dissection. (C) A second
bare-metal stent was implanted slightly overlapping with
the first stent. TIMI 3 flow was obtained.
