HRPB 524763

59-year-old Asian man with underlying hypertension, type 2 diabetes mellitus and Ischemic heart disease. He had a history of Non ST Elevation Myocardial infarction on February 2020. Cardiac catheterization showed 90% stenosis of distal LCx and chronic total occlusion of proximal LAD with good collaterals from RCA. The culprit distal LCx lesion was treated with a drug coated balloon. In view of still symptomatic, he was electively planned for proximal LAD CTO intervention.

Echocardiogram showed ejection fraction of 35% with anteroseptal hypokinesis.

Catheterization with dual injection was done using Bi- radial approach (right radiac and left distal radial/snuffbox access) to study the CTO lesion.  LM was short and smooth, ostial LAD was subtotal followed by proximal CTO with good collaterals from the RCA, distal LCx which was previously treated with a DCB showed 90% stenosis. Proximal LAD CTO segment had a clear tapered proximal cap with the lesion length of <20mm. J-CTO score was 0. RCA was dominant with minor irregularities.
Catheterization findings.mp4

Fielder XT with Finecross wired into LAD but failed crossing. Escalated to Gaia third, crossed proximal CTO using wire-based ADR. Predilated mid to proximal LAD with NC balloon 2.0 x 15 mm @ 16 ATM followed by ostial LAD – LM with NC balloon 3.0 x 15 mm @16 ATM. EBU 3.5 guide catheter was deeply engaged hitting the carina caused a retrograde coronary aortic dissection extending less than 40mm from the LM ostium (Dunning class II) and extending antegrade to the mid LAD and distal LCx. Runthrough wired into LCx, predilated distal LCx with NC balloon 2.0 x 15 mm @16 ATM. Stented mid-distal LCx with Biomime (DES) 2.5x 48 mm @ 8 ATM followed by postdilatation with stent balloon 2.5 x 48 mm @ 12 ATM. Initial dissection over the proximal LCx sealed after stent deployment. Opted for a provisional approach. Stented prox-mid LAD with XIENCE(DES) 3.0 x 28 mm @ 10 ATM and postdilated with stent balloon 3.0 x 28 mm @ 16 ATM. LM-prox LAD was stented with Cre8(DES) 3.5 x 46 mm @ 15 ATM overlapped with the latter stent. We postdilated the overlap and proximal LAD segment with NC balloon 3.0 x 15 mm @28 ATM. POT done with NC balloon 4.0 x 15mm @26 ATM. Subsequent angiography showed dissection over the LCx worsening with TIMI 2 flow. Converted to a T-stenting as bailout. Runthrough rewired into the LCx, predilated LCx with NC balloon 2.0 mm x 15 mm @ 16 ATM. Stented prox-mid LCx with Cre8(DES) 2.75 x 20 mm @ 12 ATM (overlapped) and postdilated with stent balloon 2.75 x 20 mm @ 16 ATM.
Procedure steps.mp4

Iatrogenic retrograde coronary aortic dissection is a rare and potentially catastrophic complication mostly originates from catheter-induced trauma, wire induced trauma or balloon inflation, especially to the LMCA. Surgery is the choice of treatment, but in these retrograde dissections ostial stenting is an alternative. T-stenting can be done during emergencies as access to the main branch is maintained throughout the procedure. Steps are fewer which ensures expeditious coverage of both vessels followed by the kissing and proximal optimization. It also allows operators to start with a provisional strategy and convert to T-stenting should the need arise.