Left internal mammary artery dissection during percutaneous coronary intervention and treatment

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @CESARJERONIMOVS via #CardioTwitterCase

Clinical presentation

This is a 70-year-old man whose cardiovascular risk factors include hypertension, hyperlipidemia, ex-smoking and coronary heart disease with CABG (SVG OM1-Ramus & LIMA-LAD). Admitted for unstable angina of high risk of 1 month of evolution. Myocardial perfusion SPECT 1 month previous showed significant anterior and apex ischemia.

Case management

The patient was taken to the cath Lab and the angiogram showed permeable LIMA with distal native vascular disease. During coaxial cannulation with the RunWay TM 6 Fr internal mammary guide catheter, a complicated dissection was found in the LIMA proximal segment that compromised the flow, distal TIMI I, accompanied by electrocardiographic changes in the cardiovisoscope and severe angina. It was decided quickly and carefully to pass an angioplasty guide 0.014 and to position it in a distal vessel, making sure it was in a true lumen. Direct implantation of a Resolute Onix 3.5x22mm to 16 atm was performed at the dissection site, sealing and completely recovering the flow, TIMI III. The angina disappeared and the electrocardiographic tracing was normalized.

Figure 1. Initial Angiogram LIMA to LAD

Figure 1. Initial Angiogram LIMA to LAD

Taking into account the clinical stability, coronary angioplasty was completed through LIMA in the LAD native vessel, initially angioplasty with a semi-compliant balloon 1.5x12 mm at 16 atm in the focal lesions of the distal and distal-middle segments LAD. Control angiography with suboptimal result, so ResoluteOnix stents of 2.0x12 mm were implanted at 16 atm in the distal segment and middle-distal segment and optimization with NC balloon of 2.0x8 mm at 24 atm.
Satisfactory final angiogram, without residual lesions, TIMI III flow of all vessels and catheter-induced dissection in sealed LIMA. The patient progressed satisfactorily and was discharged after 48 hours.

Figure 2. Catheter-induced LIMA dissection

Figure 2. Catheter-induced LIMA dissection

Figure 3. PCI LIMA & LAD mid-distal

Figure 3. PCI LIMA & LAD mid-distal

Author

Cesar Villalobos

@CESARJERONIMOVS

Tunja, Colombia

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