A leaking left main or a leaking stent shaft !?

#CardioTwitterCase originally published on Twitter

Contrast staining during coronary angioplasty is an ominous sign, usually indicating deep artery wedging by the guide catheter, or vessel dissection / perforation. The author presents an unusual cause of LMCA staining during primary LAD PCI.

This case was originally published on Twitter by @nadig_cardio

Case description

An elderly gentleman presented with a 12-hour history of chest pain and breathlessness. His ECG was suggestive of acute anterior STEMI. He was immediately transferred to cathlab for primary PCI. His angiogram showed total block of proximal LAD (Video 1), and flow was promptly restored with 2.5 x 12 mm balloon.

A 3 x 32 mm Sirolimus-eluting stent was negotiated across the lesion without much difficulty (Video 2). However, during stent inflation, contrast staining was noted in LMCA and the stent balloon was only partially inflated. We made another attempt to expand the stent balloon, but the inflation device would not inflate beyond 4-5 atm, and the contrast stain appeared again in LMCA (Video 3). A small puff of dye was injected to rule out dissection of LMCA, but the LMCA was clean, with no evidence of dissection.

We inferred that, possibly, the stent delivery shaft was defective, as contrast leaked from the stent shaft into LM every time we attempted to inflate stent. Any further attempt would result in contrast leakage into LMCA, which could lead to dissection and catastrophic closure of LMCA.

The stent was carefully removed, taking care not to damage the sub-expanded stent. Subsequently, a non-compact 3 x 12 balloon was used to optimally expand the stent (Figure 1). Final angiogram showed TIMI 3 flow in LAD without any damage in LMCA (Video 4).

We tested the stent delivery system externally, which confirmed our assumption of a defective shaft from which the contrast was leaking (Video 5).