06 Jan 2025
RCA hydraulic dissection: what to do?
#CardioTwitterCase originally published on Twitter
Any coronary intervention can be compromised by an iatrogenic hydraulic dissection: find out how to manage it with dissection stenting!
This case was originally published on Twitter by @MdSomov
Case description
A 38-year-old male patient underwent diagnostic angiography for chest pain, and an abnormal nuclear stress test showing 15 % ischemia.
Left system without significant stenosis. After deep engaging RCA with JL, catheter angio was performed.
Patient didn’t feel chest pain, and ECG was normal.
Due to high risk of vessel closure, our plan was to find true lumen and to cover entry point of the dissection with long stent.
Media
Final remarks
- Any coronary intervention may be disturbed by iatrogenic hydraulic dissection
- Haemodynamic monitoring from the tip of the catheter is important, making sure to use it in order to avoid catastrophic complication
- Avoid engaging RCA with JL, and don’t inject if you are not confident in catheter position
- No more contrast injections until dissection is covered with the stent
Original tweet and Twitter discussion
RCA hydrolic #dissection What to do ?@SVRaoMD@Hragy@DrBIqbal@dautov_MD@KPujdak@SanjogKalra@realarainmd@KovacicMihajlo@AgostoniPF@GLGasparinipic.twitter.com/BIf4zfSqng
— Somov MD (@MdSomov) December 12, 2024
Authors
3 comments
I'd like to add one remark: "don't panic, take a deep breath, then follow the other points". Thanks for a case of a "not so rare as thought to be" complication and valuable thoughts on the topic.
Great case...thank you for sharing this with us. This a young patient, and therefore one can anticipate no difficulties - like subclavian tortuousity or atheromatosis - to impede an easy advancement of a guiding catheter. Furthermore, it appears that the diagnostic catheter is still in the true lumen. In cases like this, usually, an LONG extra-support coronary guidewire 0.014'' (300cm) , can be easily advanced through the DIAGNOSTIC catheter to the distal RCA, therefore maintaining access to the "true-lumen". A guide-catheter then could be advanced over the long 0.014'' guidewire without risking loose of access to the true-lumen, through-out the procedure. In this way, a stent can be placed more securely without ever loosing access to the "true-lumen" and without risking the fail of rewiring due to gradually increased hematoma.
In cases of catheter-induced dissection, it is evident that advancing the guidewire into the true lumen is the most effective solution. However, the tip of the dissecting catheter is often directed toward the false lumen, as indicated by the formation of the false lumen itself. Since there is still a possibility of advancing the guidewire into the true lumen, initially attempting to advance a soft guidewire through the catheter is a valid option. However, if any resistance is felt, the guidewire is likely entering the false lumen. At that point, it is crucial to avoid further advancement and instead adjust the setup to allow for IVUS catheter insertion. If the dissection is caused by a diagnostic catheter, changing the setup from the sheath is necessary, which typically requires switching to a guide catheter and IVUS from a second access site. While angiography alone makes it difficult to distinguish between the true and false lumens, IVUS provides a clear and precise assessment. **Note:** OCT and OFDI require flushing for red blood cell removal, making their use contraindicated in this situation. Once the IVUS catheter is advanced, it becomes possible to determine the exact location of the dissection and the direction of the true lumen, allowing for rapid and straightforward guidewire passage into the true lumen. Following successful wiring, a slightly longer and smaller-diameter stent should be placed, covering the dissection. Using a large stent from the outset may lead to severe stenosis due to hematoma shift, so starting with a smaller stent and gradually upsizing is recommended. Standard stents have a mesh-like structure, which means they cannot completely block blood flow into the hematoma. However, as long as the inflow pressure into the hematoma decreases and the hematoma does not expand further, it can be managed conservatively. These hematomas are naturally absorbed over time. In some cases, despite standard stent placement, the hematoma may continue to expand or cause hemodynamic complications due to intramural pressure. For instance, I have encountered a case where catheter-induced dissection at the RCA ostium extended to the aortic valve, leading to acute aortic regurgitation (AR). In such situations, it is necessary to completely block blood flow into the hematoma using a covered stent (or multiple stents, though a covered stent is preferable). **Note:** Eliminating the hematoma by simply expanding the stent is not a viable option due to the high extensibility of the coronary adventitia. The coronary adventitia can stretch up to 1.8 times its original length under normal systolic pressure levels, making this approach impractical. Although techniques such as using a cutting balloon to fenestrate the septum can be considered when hematoma shifts, they carry the risk of hematoma progression due to the creation of a new entry or causing coronary rupture. Therefore, "rapid stenting" is the preferred approach. Finally, if wiring into the true lumen proves impossible and the situation deteriorates, an alternative approach similar to the **STAR technique in CTO PCI** can be considered. This involves using an **Intermediate Slippery Guidewire** to create a **reentry in the distal coronary artery**, thereby reducing intramural hematoma pressure and restoring true lumen flow. I have encountered a case where I unintentionally caused a severe catheter-induced dissection of the donor LAD while performing **RCA CTO PCI**, leading to a pre-shock state. In this case, the **Intermediate Slippery Guidewire** spontaneously reentered in the distal LAD, resulting in immediate hemodynamic stabilization. This allowed us to proceed with IVUS evaluation and successfully perform bailout stenting. As a last resort, this technique is worth considering in cases of severe catheter-induced dissection. https://link.springer.com/article/10.1007/s12928-024-01044-y