A 30-year-old woman with chest pain radiating to the left shoulder and dyspnea on exertion was referred to our cardiac outpatient unit for post-coronavirus disease 2019 (COVID-19) syndrome. Her symptom persisted for >1 year after recovery from the suspected COVID-19 infection, which was diagnosed at the early stage of the COVID-19 pandemic in Japan. Her left ventricular ejection fraction was slightly reduced to 54% on cine cardiovascular magnetic resonance imaging, and late gadolinium enhancement imaging demonstrated circumferential mid-wall enhancement of the left ventricle (Video 1). Although coronary computed tomography angiography (CCTA) showed no coronary abnormalities, 8 months of treatment with bisoprolol, 2.5 mg/day, was found partially effective in reducing angina symptoms, suggesting that ischemia and no obstructive coronary artery disease (INOCA) is a potential cause of angina.1 Her low blood pressure limited the use of calcium channel blockers and nitrates. Therefore, to diagnose INOCA, she underwent an invasive assessment of the coronary microcirculation. A standard 0.014-inch pressure-temperature sensor-tipped guidewire (PressureWire™ X, Abbott) was placed in the left anterior descending artery (LAD) using a 5 Fr Ikari left 4.0 guiding catheter. Coronary thermodilution curves under resting conditions were successfully obtained by repeated intracoronary bolus injections of 3 mL of saline at room temperature; however, insufficient curves were obtained during hyperemia (Fig. 1 A, yellow and green curves in the lower panel). After her fractional flow reserve dropped to 0.39, CCTA showed left main coronary artery (LMCA) dissection with LAD occlusion (Fig. 1B, red and yellow arrows, respectively; Video 2), indicating the National Heart, Lung and Blood Institute (NHLBI) classification type F dissection due to inadvertent deep-seating of the guiding catheter and the thermodilution procedure. Further, the guidewire was inadvertently removed and not advanced easily into the distal LAD. A 6 Fr Judkins left 3.5 guiding catheter was additionally engaged in the LMCA ostium. After crossing the left circumflex artery (LCX) with a 0.014-inch floppy guidewire (Asahi SION blue™, Asahi Intecc), intravascular ultrasound (IVUS) catheter was advanced into the LCX and the false lumen of the LAD. It showed intramural hematomas compressing the true lumina of the LMCA, LAD, and LCX (Fig. 1a-c/Video 3). The entry site of the false lumen was located at the bifurcation of the LMCA (Fig. 1b, blue arrow). An additional guidewire was successfully inserted into the true lumen of the LAD under real-time IVUS guidance. Because of the difficulty encountered in achieving optimal stenting, fenestrations between the true lumen and hematomas were planned. Balloon dilation in the LAD using a 2.25 × 10 mm Wolverine™ cutting balloon (Boston Scientific) and a 3.0 × 9 mm NSE Advance™ scoring balloon (Goodman) was ineffective in evacuating the hematoma. After pulling the fully-inflated Wolverine™ cutting balloon from the distal portion of the hematoma (Video 4), a fenestration was successfully created with the resolution of the hyperechoic area of the hematoma space in the LAD (Fig. 1f). However, substantial hematoma remained at the bifurcation of the LMCA. Thus, we performed kissing balloon inflation at the bifurcation using Wolverine™ balloon for LCX and NSE Advance™ for LAD at 10 atm, achieving an acceptable angiographic result (Fig. 1C/Videos 5-6). IVUS showed regression of the hematoma in the LMCA and the residual dissection with false lumen formation (Fig. 1d-e/Video 7). After the procedure, her chest pain was resolved. Follow-up CCTA demonstrated good flow in the distal LAD (Video 8).
Figure 1.
Diagnosis and management of iatrogenic coronary dissection. (A) Coronary thermodilution curves. Insufficient curves are obtained during hyperemia (yellow and green curvesin the lower panel). (B) LMCA dissection (red arrow) with LAD occlusion (yellow arrow). The white line indicates the compressed LAD. (a–c) Pre-PCI IVUS images. The Blue arrow indicates the entry site of the false lumen. (C) Final angiography shows an acceptable result. (d–f) Final IVUS shows regression of hematomas. Orange arrows indicate the guidewire in the LCX. Asterisk indicates hematomas.
Coronary artery fenestration with a cutting or scoring balloon angioplasty has recently been recognized as a useful technique for managing coronary dissection with intramural hematoma.2 , 3 Additionally, pulling back an inflated cutting balloon is used as an off-label treatment for coronary artery dissection without stenting.4 Although catheter-induced dissection of LMCA is a rare complication, caution should be exercised while inserting a guiding catheter into the LMCA and performing coronary thermodilution by bolus injection to assess flow reserve.
Conflict of interest
None.
Acknowledgments
This work was supported in part by Fukuda Foundation for Medical Technology (to Dr. Aikawa), the Akiyama Life Science Foundation (to Dr. Aikawa), Grants-in-Aid for Regional R&D Proposal-Based Program from Northern Advancement Center for Science & Technology of Hokkaido Japan (to Dr. Aikawa), the Uehara Memorial Foundation (to Dr. Aikawa), and Grants-in-Aid of The Cardiovascular Research Fund, Tokyo, Japan (to Dr. Aikawa).”
Footnotes
Peer review under responsibility of Hellenic Society of Cardiology.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.hjc.2022.02.006.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
Video 1. Late gadolinium enhancement cardiovascular magnetic resonance imaging in the axial plane. Circumferential mid-wall enhancement is seen in the left ventricle.
Video 2. LMCA dissection with LAD occlusion. Coronary angiography shows LMCA dissection with LAD occlusion after obtaining coronary thermodilution curves.
Video 3. Pre-PCI intravascular ultrasound imaging from LAD to LMCA. Intravascular ultrasound reveals intramural hematomas compressing true lumen of the LMCA, LAD, and left circumflex artery.
Video 4. Fenestration procedure for the treatment of the hematoma space in the LAD. The fully inflated Wolverine™ cutting balloon (Boston Scientific, 2.25×10 mm at 20 atm) is pulled from the distal portion of the hematoma in the LAD.
Video 5. Postprocedural coronary angiography. Straight cranial view.
Video 6. Final coronary angiography. Final coronary angiography shows an acceptable angiographic result.
Video 7. Post-PCI intravascular ultrasound imaging from LAD to LMCA. Intravascular ultrasound shows regression of the hematoma from LAD to LMCA.
Video 8. Curved planar reformatted coronary computed tomography angiography of LAD. Coronary computed tomography angiography shows the good flow of the LAD with a dissection flap and a small intramural hematoma in the middle LAD.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Video 1. Late gadolinium enhancement cardiovascular magnetic resonance imaging in the axial plane. Circumferential mid-wall enhancement is seen in the left ventricle.
Video 2. LMCA dissection with LAD occlusion. Coronary angiography shows LMCA dissection with LAD occlusion after obtaining coronary thermodilution curves.
Video 3. Pre-PCI intravascular ultrasound imaging from LAD to LMCA. Intravascular ultrasound reveals intramural hematomas compressing true lumen of the LMCA, LAD, and left circumflex artery.
Video 4. Fenestration procedure for the treatment of the hematoma space in the LAD. The fully inflated Wolverine™ cutting balloon (Boston Scientific, 2.25×10 mm at 20 atm) is pulled from the distal portion of the hematoma in the LAD.
Video 5. Postprocedural coronary angiography. Straight cranial view.
Video 6. Final coronary angiography. Final coronary angiography shows an acceptable angiographic result.
Video 7. Post-PCI intravascular ultrasound imaging from LAD to LMCA. Intravascular ultrasound shows regression of the hematoma from LAD to LMCA.
Video 8. Curved planar reformatted coronary computed tomography angiography of LAD. Coronary computed tomography angiography shows the good flow of the LAD with a dissection flap and a small intramural hematoma in the middle LAD.